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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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Successful Use of Thrombolysis in an Extremely Low Birth Weight, Premature Infant With Aortic Thrombosis. J Pediatr Hematol Oncol 2022; 44:e888-e891. [PMID: 35398856 DOI: 10.1097/mph.0000000000002455] [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: 04/23/2021] [Accepted: 02/18/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Severe neonatal aortic thrombosis is rare but can lead to significant morbidity or death if inadequately treated. Thrombolytic therapy is indicated for thrombi which are life-threatening, organ-threatening, or limb-threatening, but dosing consensus has not been established. OBSERVATION We report a case of a 700 g preterm neonate with spontaneous intestinal perforation who developed an occlusive aortic thrombus with signs of limb ischemia. He was treated successfully with tissue plasminogen activator without hemorrhagic complications. He was started at a dose of 0.06 mg/kg/h and received a maximum dose of 0.3 mg/kg/h. Long-term follow-up at 3 years and 3 months showed no negative sequelae. CONCLUSION Alteplase may be considered in premature, extremely low-birth weight infants with careful assessment of risk and benefits, along with frequent surveillance and supportive care.
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Glonnegger H, Zieger B, Grohmann J, Freund G, Zeller T, Uhl M, Stiller B. Successful Secondary Endovascular Intervention in Pediatric Patients with Venous Thromboembolic Events. Hamostaseologie 2022; 43:102-109. [PMID: 35026859 DOI: 10.1055/a-1701-2098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND In the past, pediatric patients with venous thromboembolic events (VTE) were treated with low-molecular-weight heparin (LMWH) which was successful in around 70% of the cases. However, anticoagulation alone might not restore patency in all patients, and advanced therapeutic options to prevent postthrombotic syndrome are needed. During recent years, endovascular interventions have become a treatment option for pediatric patients with persistent thrombotic occlusion, not only in life- or limb-threatening VTE. METHODS We evaluated 12 consecutive patients (11-17 years) with newly diagnosed VTE being treated at our department during the last 4 years (2017-2020). In case follow-up examination showed persistent venoocclusion under anticoagulation, patients received secondary interventional therapy like recanalization, percutaneous transluminal angioplasty with or without catheter-directed thrombolysis, and stenting. Patients with no clinical signs of venoocclusion or regredient thrombosis in imaging examination received anticoagulation alone. RESULTS Six of 12 (50%) patients underwent catheter intervention. Median time from diagnosis to intervention was 4 months (0-12 months). Reintervention was necessary in one (8%) case and complete recanalization failed in one (8%) case. There were no major bleeding events or other major postinterventional complications, no acute or late local recurrence, and all patients reported clinical improvement after the procedure. CONCLUSION If endovascular intervention is used in teenage patients with persistent symptomatic VTE, reduction of postthrombotic symptoms is possible, even if intervention is performed secondary to failure of anticoagulation. Multidisciplinary treatment decisions can be based on the clinical course and follow-up imaging.
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Affiliation(s)
- Hannah Glonnegger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center - University of Freiburg, Germany
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center - University of Freiburg, Germany
| | - Jochen Grohmann
- Department of Congenital Heart Defects and Pediatric Cardiology, Faculty of Medicine, University Heart Center Freiburg - Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany.,Department of Congenital Heart Disease/Pediatric Cardiology, Heart and Diabetes Center NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Gabriele Freund
- Department of Angiology, Faculty of Medicine, University Heart Center Freiburg - Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Thomas Zeller
- Department of Angiology, Faculty of Medicine, University Heart Center Freiburg - Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Markus Uhl
- Division of Pediatric Radiology, Department of Radiology, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Brigitte Stiller
- Department of Congenital Heart Defects and Pediatric Cardiology, Faculty of Medicine, University Heart Center Freiburg - Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
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4
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Khetarpal S. Superior Mesenteric Vein Thrombosis in a Pediatric Patient: Case Report and Review of the Literature. Pediatr Emerg Care 2021; 37:e769-e771. [PMID: 31977781 DOI: 10.1097/pec.0000000000001967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Patients with inflammatory bowel disease are at increased risk of thromboembolism. There are various sites for thromboembolism including the cerebral, limbs, abdominal vessels, retina, and lungs. Here, we report a case of a 17-year-old patient with a history of Crohn disease presenting with abdominal pain. Upon further evaluation, the patient was found to have mesenteric vein thrombosis, which was discovered on computed tomographic scan. Potential causes, contributing factors, diagnosis, and treatment are discussed here.
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5
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Sibai H, Chen R, Liu X, Falcone U, Schimmer A, Schuh A, Law A, McNamara C, Maze D, Yee K, Minden M, Chan SM, Gupta V, Murphy T, Sakurai N, Atenafu EG, Brandwein JM, Seki JT. Anticoagulation prophylaxis reduces venous thromboembolism rate in adult acute lymphoblastic leukaemia treated with asparaginase‐based therapy. Br J Haematol 2020; 191:748-754. [DOI: 10.1111/bjh.16695] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/07/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Hassan Sibai
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Ruiqi Chen
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Xing Liu
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Biostatistics Princess Margaret Cancer Centre University Health Network Toronto ON Canada
| | - Umberto Falcone
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Aaron Schimmer
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Andre Schuh
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Arjun Law
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Caroline McNamara
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Dawn Maze
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Karen Yee
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Mark Minden
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Steven M. Chan
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Vikas Gupta
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Tracy Murphy
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Naoko Sakurai
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
| | - Eshetu G. Atenafu
- Department of Biostatistics Princess Margaret Cancer Centre University Health Network Toronto ON Canada
| | | | - Jack T. Seki
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Leslie Dan Faculty of Pharmacy University of Toronto Toronto ON Canada
- Department of Pharmacy Princess Margaret Cancer Centre University Health Network Toronto ON Canada
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Rajpurkar M, Williams S, Goldenberg N, Van Ommen C, Chan A, Thomas R, Biss T. Results of a multinational survey of diagnostic and management practices of thromboembolic pulmonary embolism in children. Thromb Res 2019; 183:98-105. [DOI: 10.1016/j.thromres.2019.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/26/2019] [Accepted: 08/02/2019] [Indexed: 01/08/2023]
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Abstract
Pulmonary embolism is an uncommon but potentially life-threatening event in children. There has been increasing awareness of pulmonary embolism in children with improved survival in children with systemic disease and advancements in diagnostic modalities. However, literature regarding pulmonary embolism in children is sparse, and thus current guidelines for management of pulmonary embolism in children are extrapolated from adult literature and remain controversial. This article reviews the background and pathophysiology of venous thromboembolism, as well as current diagnostic approach and recommended management of pulmonary embolism in children.
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8
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Hartman C, Shamir R, Simchowitz V, Lohner S, Cai W, Decsi T, Braegger C, Bronsky J, Cai W, Campoy C, Carnielli V, Darmaun D, Decsi T, Domellöf M, Embleton N, Fewtrell M, Fidler Mis N, Franz A, Goulet O, Hartman C, Hill S, Hojsak I, Iacobelli S, Jochum F, Joosten K, Kolaček S, Koletzko B, Ksiazyk J, Lapillonne A, Lohner S, Mesotten D, Mihályi K, Mihatsch WA, Mimouni F, Mølgaard C, Moltu SJ, Nomayo A, Picaud JC, Prell C, Puntis J, Riskin A, Saenz De Pipaon M, Senterre T, Shamir R, Simchowitz V, Szitanyi P, Tabbers MM, Van Den Akker CH, Van Goudoever JB, Van Kempen A, Verbruggen S, Wu J, Yan W. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Complications. Clin Nutr 2018; 37:2418-2429. [DOI: 10.1016/j.clnu.2018.06.956] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 12/30/2022]
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9
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Taha MAH, Busuttil A, Bootun R, Davies AH. A systematic review of paediatric deep venous thrombolysis. Phlebology 2018; 34:179-190. [DOI: 10.1177/0268355518778660] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives The aim was to assess the effectiveness and safety of catheter-directed thrombolysis in children with deep venous thrombosis and to evaluate its long-term effect. Method and results EMBASE, Medline and Cochrane databases were searched to identify studies in which paediatric acute deep venous thrombosis patients received thrombolysis. Following title and abstract screening, seven cohort studies with a total of 183 patients were identified. Technical success was 82% and superior in regional rather than systemic thrombolysis (p < 0.00001). One cohort study identified significant difference in thrombus resolution at one year between thrombolytic and anticoagulant groups (p = 0.01). The complication rate was low, with incidence rates of major bleeding, pulmonary embolism and others at 2.8%, 1.8% and 8.4%, respectively. The overall post-thrombotic syndrome rate was 12.7%. The incidence of re-thrombosis ranged from 12.3% to 27%. Conclusion Thrombolysis for paediatric deep venous thrombosis is an effective and relatively safe therapeutic option, lowering the incidence of post-thrombotic syndrome and deep venous thrombosis recurrence.
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Affiliation(s)
- Mohamed AH Taha
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, London, UK
- Department of Vascular and Endovascular Surgery, Assiut University Hospitals, Assiut, Egypt
| | - Andrew Busuttil
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, London, UK
| | - Roshan Bootun
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, London, UK
| | - Alun H Davies
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, London, UK
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10
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Sarkar S, Misra S, Nandi M, Mondal R. A misplaced intramuscular injection and limb-threatening ischemia. J Family Med Prim Care 2018; 6:680-682. [PMID: 29417035 PMCID: PMC5787982 DOI: 10.4103/2249-4863.222058] [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] [Indexed: 11/25/2022] Open
Abstract
Femoral artery thrombosis is a rare complication of intramuscular (IM) injection in children. A 12-month-old boy presented with right lower limb ischemia and digital gangrene 3 days after an injection of ceftriaxone administered to his medial aspect of the right thigh. Successful thrombolysis and partial limb salvage was possible with enoxaparin despite a late presentation. Unnecessary and unsafe IM injection in community practice might lead to such devastating outcome which should be avoided.
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Affiliation(s)
- Sumantra Sarkar
- Department of Pediatric Medicine, Institute of Post Graduate Medical Education and Research and SSKM Hospital, Kolkata, West Bengal, India
| | - Sarbani Misra
- Department of Pediatric Medicine, Institute of Post Graduate Medical Education and Research and SSKM Hospital, Kolkata, West Bengal, India
| | - Madhumita Nandi
- Department of Pediatric Medicine, NRS Medical College, Kolkata, West Bengal, India
| | - Rakesh Mondal
- Department of Pediatric Medicine, Medical College, Kolkata, West Bengal, India
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11
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Annibali O, Napolitano M, Avvisati G, Siragusa S. Incidence of venous thromboembolism and use of anticoagulation in hematological malignancies: Critical review of the literature. Crit Rev Oncol Hematol 2018; 124:41-50. [PMID: 29548485 DOI: 10.1016/j.critrevonc.2018.02.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 12/04/2017] [Accepted: 02/01/2018] [Indexed: 12/21/2022] Open
Abstract
Venous Thromboembolism (VTE) frequently complicates the course of hematologic malignancies (HM) and its incidence is similar to that observed in high-risk solid tumors. Despite that, pharmacologic prophylaxis and treatment of VTE in patients with HM is challenging, mainly because a severe thrombocytopenia frequently complicates the course of treatments or may be present since diagnosis, thus increasing the risk of bleeding. Therefore, in this setting, safe and effective methods of VTE prophylaxis and treatment have not been well defined and hematologists generally refer to guidelines produced for cancer patients that give indications on anticoagulation in patients with thrombocytopenia. In this review, besides to summarize the incidence and the available data on prophylaxis and treatment of VTE in HM, we give some advices on how to use antithrombotic drugs in patients with HM according to platelets count.
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Affiliation(s)
- Ombretta Annibali
- Hematology and Stem Cell Transplantation Unit, University Campus Bio-Medico, Italy
| | - Mariasanta Napolitano
- Hematology Unit, Reference Regional Center for Thrombosis and Haemostasis, University of Palermo, Italy.
| | - Giuseppe Avvisati
- Hematology and Stem Cell Transplantation Unit, University Campus Bio-Medico, Italy
| | - Sergio Siragusa
- Hematology Unit, Reference Regional Center for Thrombosis and Haemostasis, University of Palermo, Italy
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12
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Efficacy and safety of recombinant tissue plasminogen activator for venous thrombosis after paediatric heart surgery. Cardiol Young 2018; 28:214-221. [PMID: 28889818 DOI: 10.1017/s104795111700172x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Reports in the literature of treatment with recombinant tissue plasminogen activator following cardiac surgery are limited. We reviewed our experience to provide a case series of the therapeutic use of tissue plasminogen activator for the treatment of venous thrombosis in children after cardiac surgery. The data describe the morbidity, mortality, and clinical outcomes of tissue plasminogen activator administration for treatment of venous thrombosis in children following cardiac surgery. DESIGN The study was designed as a retrospective case series. SETTING The study was carried out in a 25-bed cardiac intensive care unit in an academic, free-standing paediatric hospital. Patients All children who received tissue plasminogen activator for venous thrombosis within 60 days of cardiac surgery, a total of 13 patients, were included. Interventions Data was collected, collated, and analysed as a part of the interventions of this study. Measurements and main results Patients treated with tissue plasminogen activator were principally young infants (median 0.2, IQR 0.07-0.58 years) who had recently (22, IQR 12.5-27.3 days) undergone cardiac surgery. Hospital mortality was high in this patient group (38%), but there was no mortality attributable to tissue plasminogen activator administration, occurring within <72 hours. There was one major haemorrhagic complication that may be attributable to tissue plasminogen activator. Complete or partial resolution of venous thrombosis was confirmed using imaging in 10 of 13 patients (77%), and tissue plasminogen activator administration was associated with resolution of chylous drainage, with no drainage through chest tubes, at 10 days after tissue plasminogen activator treatment in seven of nine patients who had upper-compartment venous thrombosis-associated chylothorax. CONCLUSIONS On the basis of our experience with administration of tissue plasminogen activator in children after cardiac surgery, tissue plasminogen activator is both safe and effective for resolution of venous thrombosis in this high-risk population.
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13
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Crystal MA. Thrombolytic Use in Children: Breaking Down Barriers. J Pediatr 2016; 171:12-3. [PMID: 26778259 DOI: 10.1016/j.jpeds.2015.12.068] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 12/23/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Matthew A Crystal
- Columbia University Medical Center, Morgan Stanley Children's Hospital of New York-New York Presbyterian Hospital, New York, New York.
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14
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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Anticoagulation and Thrombolysis. Pediatr Crit Care Med 2016; 17:S77-88. [PMID: 26945332 DOI: 10.1097/pcc.0000000000000623] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Thrombotic complications are increasingly being recognized as a significant cause of morbidity and mortality in pediatric and congenital heart disease. The objective of this article is to review the medications currently available to prevent and treat such complications. DATA SOURCES Online searches were conducted using PubMed. STUDY SELECTION Studies were selected for inclusion based on their scientific merit and applicability to the pediatric cardiac population. DATA EXTRACTION Pertinent information from each selected study or scientific review was extracted for inclusion. DATA SYNTHESIS Four classes of medications were identified as potentially beneficial in this patient group: anticoagulants, antiplatelet agents, thrombolytic agents, and novel oral anticoagulants. Data on each class of medication were synthesized into the follow sections: mechanism of action, pharmacokinetics, dosing, monitoring, reversal, considerations for use, and evidence to support. CONCLUSIONS Anticoagulants, antiplatelet agents, and thrombolytic agents are routinely used successfully in the pediatric patient with heart disease for the prevention and treatment of a wide range of thrombotic complications. Although the novel oral anticoagulants have been approved for a limited number of indications in adults, studies on the safety and efficacy of these agents in children are pending.
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15
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Manlhiot C, Brandão LR, Schwartz SM, Sivarajan VB, Williams S, Collins TH, McCrindle BW. Management and Outcomes of Patients with Occlusive Thrombosis after Pediatric Cardiac Surgery. J Pediatr 2016; 169:146-53. [PMID: 26589345 DOI: 10.1016/j.jpeds.2015.10.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 08/24/2015] [Accepted: 10/13/2015] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To evaluate management and outcomes of thrombosis after pediatric cardiac surgery and stratify thrombi according to risk of short- and long-term complications to better guide therapeutic choices. STUDY DESIGN Retrospective review was performed of 513 thrombi (400 occlusive) diagnosed after 213 pediatric cardiac operations. Long-term outcomes over time were assessed with the use of parametric hazard regression models. RESULTS Serious complications and/or high-intensity treatment occurred with 17%-24% of thrombi depending on location, most commonly in thrombi affecting the cardiac and cerebral circulation. Bleeding complications affected 13% of patients; associated factors included thrombolytics (OR 8.7, P < .001), greater daily dose of unfractionated heparin (OR 1.25 per 5 U/kg/day, P = .03), and extracorporeal support (OR 4.5, P = .007). Radiologic thrombus persistence was identified in 30% ± 3% at 12 months; associated factors included extracorporeal support (hazard ratio [HR] 1.9, P = .003), venous (HR 1.7, P = .003), and occlusive thrombi at presentation (HR 1.8, P = .001); greater oxygen saturation before surgery (HR 1.13/10%, P = .05) and thrombi in femoral veins (HR 1.9, P = .001) were associated with increased hazard of resolution. Freedom from postthrombotic syndrome was 83% ± 4% at 6 years, greater number of persistent vessel segment occlusions (HR 1.8/vessel, P = .001) and greater fibrinogen at diagnosis (HR 1.1 per g/L, P = .02) were associated with increased hazard. CONCLUSIONS Thrombosis outcomes after pediatric cardiac surgery remain suboptimal. Given that more intensive treatment would likely increase the risk of bleeding, the focus should be on both thrombosis-prevention strategies, as well as in tailoring therapy according to a thrombosis outcome risk stratification approach.
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Affiliation(s)
- Cedric Manlhiot
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Leonardo R Brandão
- Division of Hematology/Oncology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Steven M Schwartz
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - V Ben Sivarajan
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Suzan Williams
- Division of Hematology/Oncology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Tanveer H Collins
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Brian W McCrindle
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada.
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16
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Álvarez Z P, Verdugo L P, Carvajal K L, Múhlhausen M G, Ríos A P, Rodríguez V D. [Recombinant tissue plasminogen activator for the management of intracardiac thrombi in newborns]. ACTA ACUST UNITED AC 2015; 86:194-9. [PMID: 26235268 DOI: 10.1016/j.rchipe.2015.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 03/30/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The incidence of cardiac thrombi in newborns has increased with the use of central venous catheters. Thrombolysis with recombinant tissue plasminogen activator (rTPA) has been used as an alternative to heparin in life threatening giant thrombus and embolization. The aim of this study is to describe the response and complications related to the use of rTPA in the management of life- threatening cardiac thrombi in newborns. PATIENTS AND METHOD The medical records of 8 newborn were reviewed in a retrospective study, of whom 7 were preterm with cardiac thrombi, and rTPA was used in all of them. RESULTS The patients included 4 males with a mean weight of 1580 gr. The principal pathology was sepsis (7/8), all of them used venous central catheter. The superior vena cava was the most frequent location, with a mean time of installation before the diagnosis of 12 days. RN 7/8 thrombi were located in the right atrium with a size between 7 to 20 mm. Three patients received low molecular weight heparin prior to using rTPA. They received between 1 to 5 cycles with rTPA. In 4 patients complete resolution of the thrombus was achieved in a mean of 3.5 days. Four patients had intracranial haemorrhage grade I, without sequelae at follow-up. There were no deaths or embolism. CONCLUSION This study is the first series of infants treated with rTPA in Chile, and where its use has quickly achieved complete resolution of the thrombus in 50% of cases, and partially in the others, thus reducing the secondary life-threatening risk of this disease.
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Affiliation(s)
- Patricia Álvarez Z
- Hospital Roberto del Río, Santiago, Chile; Departamento de Pediatría Norte, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Clínica Alemana de Santiago, Santiago, Chile.
| | - Patricia Verdugo L
- Hospital Roberto del Río, Santiago, Chile; Departamento de Pediatría Norte, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Clínica Santa María, Santiago, Chile
| | | | - Germán Múhlhausen M
- Departamento de Pediatría Norte, Facultad de Medicina, Universidad de Chile, Santiago, Chile; Servicio de Neonatología, Hospital San José, Santiago, Chile
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Kukreja KU, Lungren MP, Patel MN, Johnson ND, Racadio JM, Dandoy C, Tarango C. Endovascular venous thrombolysis in children younger than 24 months. J Vasc Interv Radiol 2014; 25:1158-64. [PMID: 24909354 DOI: 10.1016/j.jvir.2014.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Revised: 04/03/2014] [Accepted: 04/03/2014] [Indexed: 10/25/2022] Open
Abstract
PURPOSE To evaluate the technical feasibility and safety of percutaneous endovascular thrombolysis for extremity deep venous thrombosis (DVT) in children < 24 months old. MATERIALS AND METHODS A retrospective chart review of a clinical and imaging database was performed for pediatric patients who underwent endovascular therapy for DVT between January 2010 and July 2013. Indications, techniques, technical and clinical success, and complications were reviewed. Techniques for thrombolysis included catheter-directed therapy (CDT) using alteplase infusion via a multi-side hole catheter, mechanical thrombectomy, and angioplasty. Short-term outcomes were assessed using surgical and imaging follow-up examinations for patency of the targeted vessel. Patients included 11 children (mean age, 9 mo; range, 3 wk-23 mo) who consecutively underwent endovascular thrombolysis for upper extremity (n = 6) or lower extremity (n = 5) DVT. The most common indication was preservation of venous access for future cardiac surgery or medical therapy. RESULTS The most common risk factor was the presence of a central venous catheter (10 of 11 patients). All patients with upper extremity DVT had congenital heart disease. CDT and angioplasty were performed in all patients. Venous patency was established in all patients. A grade III (95%-100%) thrombolysis response was achieved in seven patients, and a grade II (50%-95%) thrombolysis response was achieved in four patients. A major complication of pulmonary embolism occurred in one patient with upper extremity thrombolysis and was managed by intravenous systemic alteplase and heparin. No recurrence of thrombosis was found on average follow-up of 11.8 months (range, 1-41 mo). CONCLUSIONS Percutaneous endovascular thrombolysis for extremity DVT is safe and technically feasible in children < 24 months old.
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Affiliation(s)
- Kamlesh U Kukreja
- Department of Radiology, Baylor College of Medicine & Texas Children's Hospital, 6701 Fannin St, Suite 470, Houston, TX 77030.
| | - Matthew P Lungren
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Manish N Patel
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Neil D Johnson
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - John M Racadio
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Christopher Dandoy
- Department of Radiology and Hematology & Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Cristina Tarango
- Department of Radiology and Hematology & Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Abstract
PURPOSE OF REVIEW To review the current literature on venous thromboembolism (VTE) in critically ill children. RECENT FINDINGS There is an increasing concern for VTE and its complications in critically ill children. Critically ill children are at increased risk of thromboembolism because of the treatment that they are receiving and their underlying condition. A complex relationship exists between thrombosis and infection. A thrombus is a nidus for infection, while infection increases the risk of thrombosis. Pediatric-specific guidelines for the prevention and treatment of thromboembolism are lacking. Current guidelines are based on the data from adults. Novel anticoagulants are now available for use in adults. Studies are ongoing to determine their safety in children. Risk assessment tools have recently been developed to determine the risk of thromboembolism in critically ill children. Certain molecules are associated with thromboembolism in adults. SUMMARY Pediatric critical care practitioners should be cognizant of the importance of VTE in critically ill children to allow early identification and treatment. Adequately powered clinical trials are critically needed to generate evidence that will guide the treatment and prevention of thromboembolism in critically ill children. Risk assessment tools that incorporate biomarkers may improve our ability to predict the occurrence of thromboembolism in critically ill children.
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Abstract
Pediatric deep vein thrombosis is an increasingly recognized phenomenon, especially with advances in treatment and supportive care of critically ill children and with better diagnostic capabilities. High-quality evidence and uniform management guidelines for antithrombotic treatment, particularly thrombolytic therapy, remain limited. Optimal dosing, intensity and duration strategies for anticoagulation as well as thrombolytic regimens that maximize efficacy and safety need to be determined through well-designed clinical trials using use of a risk-stratified approach.
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20
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Zia AN, Chitlur M. Management of thrombotic complications in acute lymphoblastic leukemia. Indian J Pediatr 2013; 80:853-62. [PMID: 23912824 DOI: 10.1007/s12098-013-1158-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 06/20/2013] [Indexed: 01/03/2023]
Abstract
Acute lymphoblastic leukemia (ALL) is the most common type of cancer diagnosed in children, and has been reported as the most common malignancy associated with thromboembolism in the pediatric age group. Treatment with Escherichia coli asparaginase, concomitant steroids, presence of central venous lines, and thrombophilic abnormalities are established risk factors for thromboembolism. The incidence varies with age, co-morbidities and chemotherapy regimens but the risk is highest during the induction and intensification phases. Treatment is necessary in majority of children to prevent serious sequelae. Mortality from thromboembolic events in any location is 2 to 4 % and the risk of recurrence is 7 to 10 %, further enhanced in the setting of malignancy. Randomized trials of venous thromboembolism (VTE) management in pediatric patients with ALL are lacking due to the low overall incidence, resulting in considerable variation in practice. The objective of this article is to review current knowledge on the treatment and prevention of thrombosis associated with pediatric ALL.
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Affiliation(s)
- Ayesha N Zia
- Carman and Ann Adams Department of Pediatrics, Division of Hematology/Oncology, Wayne State University School of Medicine, Detroit, MI, USA,
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21
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Abstract
Abstract
The incidence of venous thromboembolism (VTE) in the pediatric population is increasing. Technological advances in medicine and imaging techniques, improved awareness of the disease, and longer survival of life-threatening or chronic medical conditions all contribute to the increase in VTE rates. There is a paucity of data on management of VTE based on properly designed clinical trials, but there is significant advancement in the last 2 decades. This review summarizes the progress made in pediatric thrombosis, including epidemiological changes, advances in anticoagulant agents, and outcomes of VTE.
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22
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Giglia TM, DiNardo J, Ghanayem NS, Ichord R, Niebler RA, Odegard KC, Massicotte MP, Yates AR, Laussen PC, Tweddell JS. Bleeding and Thrombotic Emergencies in Pediatric Cardiac Intensive Care. World J Pediatr Congenit Heart Surg 2012; 3:470-91. [DOI: 10.1177/2150135112460866] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Children in the cardiac intensive care unit (CICU) with congenital or acquired heart disease are at risk for hematologic complications, both hemorrhage and thrombosis. The overall incidence of hematologic complications in the CICU is unknown, but risk factors and target groups have been identified where the essential physiologic balance between bleeding and clotting has been disrupted. Although the best management of life-threatening bleeding and clotting is prevention, the cardiac intensivist is often faced with managing life-threatening hematologic events involving patients from within the unit or those who present from outside. Part I of this review deals with the propensity of children with congenital and acquired heart disease to complications of both bleeding and clotting, and includes discussions of perioperative bleeding, thromboses in single-ventricle patients, clotting of Blalock-Taussig shunts and thrombotic complications of mechanical valves. Part II deals with the subject of stroke in children with heart disease. Part III reviews monitoring the effectiveness of anticoagulation and thrombolysis in the CICU. Currently available diagnostics modalities, medications and management strategies are reviewed and future directions discussed.
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Affiliation(s)
- Therese M. Giglia
- Division of Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - James DiNardo
- Division of Cardiac Anesthesia, Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nancy S. Ghanayem
- Division of Critical Care, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Rebecca Ichord
- Division of Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Robert A. Niebler
- Division of Critical Care, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Kirsten C. Odegard
- Division of Cardiovascular Critical Care, Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - M. Patricia Massicotte
- Department of Pediatrics, Stoller Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew R. Yates
- Sections of Cardiology and Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Peter C. Laussen
- Division of Cardiovascular Critical Care, Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - James S. Tweddell
- Division of Critical Care, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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23
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Darbari DS, Desai D, Arnaldez F, Desai K, Kallen J, Strouse J, Streiff MB, Hong K, Takemoto CM. Safety and efficacy of catheter directed thrombolysis in children with deep venous thrombosis. Br J Haematol 2012; 159:376-8. [PMID: 22934795 DOI: 10.1111/bjh.12025] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kerlin BA. Current and future management of pediatric venous thromboembolism. Am J Hematol 2012; 87 Suppl 1:S68-74. [PMID: 22367975 DOI: 10.1002/ajh.23131] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 01/17/2012] [Accepted: 01/18/2012] [Indexed: 01/17/2023]
Abstract
Venous thromboembolism (VTE) is an increasingly common complication encountered in tertiary care pediatric settings. The purpose of this review is to summarize the epidemiology, current and emerging pharmacotherapeutic options, and management of this disease. Over 70% of VTE occur in children with chronic diseases. Although they are seen in children of all ages, adolescents are at greatest risk. Pediatric VTE is associated with an increased risk of in-hospital mortality; recurrent VTE and post-thrombotic syndrome are commonly seen in survivors. In recent years, anticoagulation with low molecular weight heparin has emerged as the mainstay of therapy, but compliance is limited by its onerous subcutaneous administration route. New anticoagulants either already approved for use in adults or in the pipeline offer the possibility of improved dose stability and oral routes of administration. Current recommended anticoagulation course durations are derived from very limited case series and cohort data, or extrapolations from adult literature. However, the pathophysiologic underpinnings of pediatric VTE are dissimilar from those seen in adults and are often variable within groups of pediatric patients. Clinical studies and trials in pediatric VTE are underway which will hopefully improve the quality of evidence from which therapeutic guidelines are derived.
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Affiliation(s)
- Bryce A Kerlin
- Division of Hem/Onc/BMT, Nationwide Children's Hospital, Columbus, Ohio, USA.
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25
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Monagle P, Chan AKC, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Göttl U, Vesely SK. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e737S-e801S. [PMID: 22315277 DOI: 10.1378/chest.11-2308] [Citation(s) in RCA: 950] [Impact Index Per Article: 79.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Neonates and children differ from adults in physiology, pharmacologic responses to drugs, epidemiology, and long-term consequences of thrombosis. This guideline addresses optimal strategies for the management of thrombosis in neonates and children. METHODS The methods of this guideline follow those described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. RESULTS We suggest that where possible, pediatric hematologists with experience in thromboembolism manage pediatric patients with thromboembolism (Grade 2C). When this is not possible, we suggest a combination of a neonatologist/pediatrician and adult hematologist supported by consultation with an experienced pediatric hematologist (Grade 2C). We suggest that therapeutic unfractionated heparin in children is titrated to achieve a target anti-Xa range of 0.35 to 0.7 units/mL or an activated partial thromboplastin time range that correlates to this anti-Xa range or to a protamine titration range of 0.2 to 0.4 units/mL (Grade 2C). For neonates and children receiving either daily or bid therapeutic low-molecular-weight heparin, we suggest that the drug be monitored to a target range of 0.5 to 1.0 units/mL in a sample taken 4 to 6 h after subcutaneous injection or, alternatively, 0.5 to 0.8 units/mL in a sample taken 2 to 6 h after subcutaneous injection (Grade 2C). CONCLUSIONS The evidence supporting most recommendations for antithrombotic therapy in neonates and children remains weak. Studies addressing appropriate drug target ranges and monitoring requirements are urgently required in addition to site- and clinical situation-specific thrombosis management strategies.
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Affiliation(s)
- Paul Monagle
- Haematology Department, The Royal Children's Hospital, Department of Paediatrics, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Anthony K C Chan
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Neil A Goldenberg
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplantation and Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, Aurora, CO
| | - Rebecca N Ichord
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Janna M Journeycake
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
| | - Ulrike Nowak-Göttl
- Thrombosis and Hemostasis Unit, Institute of Clinical Chemistry, University Hospital Kiel, Kiel, Germany
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
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26
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Santiago MJ, López-Herce J, Zarzoso S, Sánchez A, Mencía S, Carrillo A. [Thrombolytic therapy using a low dose of tissue plasminogen activator in children]. An Pediatr (Barc) 2011; 76:77-82. [PMID: 21982548 DOI: 10.1016/j.anpedi.2011.07.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Revised: 07/28/2011] [Accepted: 07/29/2011] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To analyse the efficacy and side effects of low doses of tissue plasminogen activator for the treatment of acute arterial and/or venous thrombosis in children. PATIENTS AND METHODS Prospective observational clinical study. 18 children between 1 months and 11 years treated with low doses (0.01-0.06 mg/kg/h) of continuous intravenous thrombolytic therapy with t-PA were studied. RESULTS A total of 94% of patients improved with low doses t-PA (72% complete resolution of the thrombosis and 22% partial resolution). One patient suffered a severe haemorrhage secondary to t-Pa and had to stop the treatment. The incidence of severe side effects was low (5%) CONCLUSIONS Thrombolytic therapy with low doses of t-PA (0.01-0.05 mg/kg/h) is effective in a high percentage of children with acute arterial and/or venous thrombosis and produces a relatively low frequency of side effects.
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Affiliation(s)
- M J Santiago
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, España
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O'Brien SH. Recognition and Management of Pediatric Venous Thromboembolism in the Emergency Department. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2011. [DOI: 10.1016/j.cpem.2011.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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28
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Goldenberg NA, Branchford B, Wang M, Ray C, Durham JD, Manco-Johnson MJ. Percutaneous mechanical and pharmacomechanical thrombolysis for occlusive deep vein thrombosis of the proximal limb in adolescent subjects: findings from an institution-based prospective inception cohort study of pediatric venous thromboembolism. J Vasc Interv Radiol 2011; 22:121-32. [PMID: 21216157 PMCID: PMC3058325 DOI: 10.1016/j.jvir.2010.10.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2010] [Revised: 10/10/2010] [Accepted: 10/16/2010] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Young individuals with occlusive, proximal-limb deep vein thrombosis (DVT) who have acutely increased plasma levels of factor VIII and D-dimer are at high risk for postthrombotic syndrome (PTS) when treated with conventional anticoagulation alone. The present report is an evaluation of experience with adjunctive percutaneous mechanical thrombolysis (PMT) and/or percutaneous pharmacomechanical thrombolysis (PPMT) in such patients. PATIENTS AND METHODS Among 95 children 11-21 years of age enrolled in a prospective cohort of venous thromboembolism between March 1, 2006, and November 1, 2009, 16 met eligibility criteria and underwent PMT/PPMT, typically with adjunctive catheter-directed thrombolytic infusion (CDTI) of tissue-type plasminogen activator given after the procedure. RESULTS Median age was 16 years (range, 11-19 y). Thirteen cases (81%) involved lower limbs. Underlying stenotic lesions were disclosed in 53%, with endovascular stents deployed in all cases of May-Thurner anomaly. There were no periprocedural major bleeding events and one symptomatic pulmonary embolism. Technical success rate was 94%. Early (< 30 days) locally recurrent DVT developed in 40% of cases, of which 83% were successfully treated with repeat lysis. Late recurrent DVT rate (median follow-up duration, 14 months; range, 1-42 mo) was 27%. Cumulative incidence of physically and functionally significant PTS at 1-2 years was 13%. CONCLUSIONS This experience provides preliminary evidence that PMT/PPMT with adjunctive CDTI can be used safely and effectively in adolescent subjects with DVT at high risk for PTS.
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Affiliation(s)
- Neil A Goldenberg
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplantation and Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, Aurora, Colorado 80045, USA.
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Pena V, Watson AJ, Kvedar JC, Grant RW. Mobile phone technology for children with type 1 and type 2 diabetes: a parent survey. J Diabetes Sci Technol 2009; 3:1481-9. [PMID: 20144404 PMCID: PMC2787050 DOI: 10.1177/193229680900300630] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The novel application of information technology has the potential to improve care for children with diabetes. We surveyed parents of children with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) to (1) identify their concerns related to their children's diabetes and (2) assess the relationship between these concerns and parental attitudes toward a glucometer integrated into a mobile phone that could provide parents and health care providers with a child's real-time glucose readings via text message and a secure Web site. METHODS We conducted a cross-sectional Web-based survey of parents with children ages 10-19 years (125 with T1DM and 77 with T2DM). Parental concerns were grouped by (1) access to their child's provider, (2) parenting challenges, and (3) knowledge about managing their child's diabetes. RESULTS Parental concerns focused mostly on access to their child's health care provider. Over half of respondents expressed interest in subscribing to a mobile-phone-based service. In multivariate logistic regression models, the odds of being willing to use the service increased if parents had concerns about provider access, a child with T2DM, a college education, or currently subscribed to text messaging. Enthusiasm decreased with increasing annual service cost. CONCLUSIONS Study participants-particularly parents with provider access concerns or a child with T2DM-were receptive to adopting novel health technology to help manage their children's diabetes. Adoption of such tools is most likely driven by the unmet needs of parents.
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MESH Headings
- Adolescent
- Adult
- Blood Glucose/metabolism
- Blood Glucose Self-Monitoring/economics
- Blood Glucose Self-Monitoring/instrumentation
- Cell Phone/economics
- Child
- Cross-Sectional Studies
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/diagnosis
- Diabetes Mellitus, Type 1/economics
- Diabetes Mellitus, Type 1/psychology
- Diabetes Mellitus, Type 1/therapy
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/diagnosis
- Diabetes Mellitus, Type 2/economics
- Diabetes Mellitus, Type 2/psychology
- Diabetes Mellitus, Type 2/therapy
- Diagnostic Equipment/economics
- Female
- Health Care Costs
- Health Care Surveys
- Health Knowledge, Attitudes, Practice
- Health Services Accessibility
- Humans
- Internet
- Logistic Models
- Male
- Middle Aged
- Motivation
- Parent-Child Relations
- Parents/psychology
- Patient Acceptance of Health Care
- Predictive Value of Tests
- Surveys and Questionnaires
- Time Factors
- Young Adult
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Affiliation(s)
- Venessa Pena
- Center for Connected Health, Boston, Massachusetts, USA
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