Central Venous Catheter-Related Deep Vein Thrombosis in the Pediatric Cardiac Intensive Care Unit

Risk factors and incidence of central venous access device-related thrombosis in hospitalized children: a systematic review and meta-analysis

BACKGROUND

The risk factors for central venous access device-related thrombosis (CRT) in children are not fully understood. We used evidence-based medicine to find the risk factors for CRT by pooling current studies reporting risk factors of CRT, aiming to guide clinical diagnosis and treatment.

METHODS

A systematic search of PubMed, Web of Science, Embase, Cochrane Library, Scopus, CNKI, Sinomed, and Wanfang databases was conducted. RevMan 5.4 was employed for data analysis.

RESULTS

The review included 47 studies evaluating 262,587 children with CVAD placement. Qualitative synthesis and quantitative meta-analysis identified D-dimer, location of insertion, type of catheter, number of lumens, catheter indwelling time, and central line-associated bloodstream infection as the most critical risk factors for CRT. Primarily due to observational design, the quality of evidence was regarded as low certainty for these risk factors according to the GRADE approach.

CONCLUSION

Because fewer high-quality studies are available, larger sample sizes and well-designed prospective studies are still needed to clarify the risk factors affecting CRT. In the future, developing pediatric-specific CRT risk assessment tools is important. Appropriate stratified preventive strategies for CRT according to risk assessment level will help improve clinical efficiency, avoid the occurrence of CRT, and alleviate unnecessary suffering of children.

IMPACT

This is the latest systematic review of risk factors and incidence of CRT in children. A total of 47 studies involving 262,587 patients were included in our meta-analysis, according to which the pooled prevalence of CRT was 9.1%. This study identified several of the most critical risk factors affecting CRT in children, including D-dimer, insertion location, type of catheter, number of lumens, catheter indwelling time, and central line-associated bloodstream infection (CLABSI).

Risk factors for venous thromboembolism in a single pediatric intensive care unit in China

BACKGROUND

Analyses of extensive, nationally representative databases indicate a rising prevalence of venous thromboembolism (VTE) among critically ill children. However, the majority of studies on childhood VTE have primarily concentrated on Caucasian populations in the United States and European countries. There is a lack of epidemiological studies on VTE in Chinese children.

METHODS

We conducted a retrospective cohort study of data from the Pediatric Intensive Care (PIC) database. Data were obtained and extracted by using Structured Query Language (SQL) and the administrative platform pgAdmin4 for PostgreSQL. Bivariate analyses were conducted in which categorical variables were analyzed by a chi-square test and continuous variables were analyzed by a Student's t-test. Separate multivariable logistic regressions were employed to investigate the associations between VTE and sociodemographic factors as well as clinical factors.

RESULTS

Our study included 12,881 pediatric patients from the PIC database, spanning the years 2010 to 2018. The incidence rate of pediatric VTE was 0.19% (24/12,881). The venous thrombotic locations were deep venous thrombosis extremities (n = 18), superior vena cava (n = 1), cerebral sinovenous (n = 1), and other deep venous thrombosis (n = 4). Univariate analysis showed that age, weight, shock, sepsis, cancer and vasopressor receipt were statistically significant risk factors for pediatric VTE (all p ≤ 0.05). After multivariable logistic regression analysis, only shock (aOR: 6.77, 95%CI: 1.33-34.73, p = 0.019) and admission for sepsis (aOR: 6.09, 95%CI: 1.76-21.09, p = 0.004) were statistically significant associated with pediatric VTE.

CONCLUSIONS

In conclusion, data obtained from the Pediatric Intensive Care (PIC) database revealed a prevalence of VTE in pediatric patients of 0.19%. The most common location for venous thrombi was deep venous thrombosis (DVT) in the extremities. We identified that shock and sepsis were statistically significant factors associated with pediatric VTE.

Dabigatran for Treatment and Secondary Prevention of Venous Thromboembolism in Pediatric Congenital Heart Disease

BACKGROUND

Congenital heart disease (CHD) is common in children and associated with greater risk of thrombotic complications. Management of these complications with standard-of-care treatment is suboptimal for these children.

METHODS AND RESULTS

The effectiveness and safety of dabigatran were demonstrated in pivotal pediatric studies for the treatment of acute venous thromboembolism (VTE; NCT01895777) and secondary VTE prevention (NCT02197416). We report safety and efficacy outcomes from subgroup analyses of these studies for children with CHD (diagnosed according to local practice) and those without. In NCT01895777, 17/21 (81.0%) and 16/27 (59.3%) patients with CHD (including cyanotic) treated with dabigatran and standard of care, respectively, met the primary end point (complete thrombus resolution, freedom from recurrent VTE, and freedom from VTE-related death; odds ratio [OR], 0.34 [95% CI, 0.08-1.23]). In patients without CHD, 41.0% (n=64) versus 34.9% (n=22) achieved this end point with the respective treatments (OR, 0.77 [95% CI, 0.42-1.41]). Although numerical differences were observed, no heterogeneity in treatment effect of dabigatran on the composite primary end point was detected in patients with and without CHD (interaction P =0.2674). In NCT02197416, recurrent VTE at 12 months occurred in 0/17 patients with CHD versus 3/194 (1.5%) without. No patient with CHD experienced major or clinically relevant nonmajor bleeding events.

CONCLUSIONS

Data on favorable anticoagulant alternatives for the unmet needs of children with CHD are emerging, and our exploratory results suggest that dabigatran could be an appropriate treatment choice, although challenging sample size limitations in pediatric studies require cautious interpretation of findings.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01895777, NCT02197416.

Risk factors for long post-operative hospital stays after cardiopulmonary bypass surgery in full-term neonates

BACKGROUND

Long hospital stays for neonates following cardiac surgery can be detrimental to short- and long-term outcomes. Furthermore, it can impact resource allocation within heart centres' daily operations. We aimed to explore multiple clinical variables and complications that can influence and predict the post-operative hospital length of stay.

METHODS

We conducted a retrospective observational review of the full-term neonates (<30 days old) who had cardiac surgery in a tertiary paediatric cardiac surgery centre - assessment of multiple clinical variables and their association with post-operative hospital length of stay.

RESULTS

A total of 273 neonates were screened with a mortality rate of 8%. The survivors (number = 251) were analysed; 83% had at least one complication. The median post-operative hospital length of stay was 19.5 days (interquartile range 10.5, 31.6 days). The median post-operative hospital length of stay was significantly different among patients with complications (21.5 days, 10.5, 34.6 days) versus the no-complication group (14 days, 9.6, 19.5 days), p < 0.01. Among the non-modifiable variables, gastrostomy, tracheostomy, syndromes, and single ventricle physiology are significantly associated with longer post-operative hospital length of stay. Among the modifiable variables, deep vein thrombosis and cardiac arrest were associated with extended post-operative hospital length of stay.

CONCLUSIONS

Complications following cardiac surgery can be associated with longer hospital stay. Some complications are modifiable. Deep vein thrombosis and cardiac arrest are among the complications that were associated with longer hospital stay and offer a direct opportunity for prevention which may be reflected in better outcomes and shorter hospital stay.

Development and validation of a nomogram model for central venous access device-related thrombosis in hospitalized children

This study aimed to develop and validate a nomogram model of central venous access device-related thrombosis (CRT) for hospitalized children. A total of 503 consecutive cases from a hospital in Changsha City, Hunan Province were stochastically classified into the training set and internal validation set at a ratio of 7:3, and 85 consecutive cases in two hospitals in Urumqi City, Xinjiang Uygur Autonomous Region were collected as an external validation set. Univariate analysis and multivariate analysis on CRT-related risk factors of hospitalized children were conducted, a logistic regression model was employed to establish the nomogram, and the discrimination, calibration, and decision curve analysis was performed to assess the proposed nomogram model. The nomogram model involved seven independent risk factors, including blind catheterization, abnormal liver function, central line-associated bloodstream infection, infection, number of catheter lines, leukemia, and bed rest > 72 h. The discrimination results showed that the area under the receiver operating characteristic curve of the training set, internal validation set, and external validation set was 0.74, 0.71, and 0.76 respectively, and the accuracy rates of the proposed nomogram model were 79%, 72%, and 71% in the training set, internal validation set, and external validation set. The calibration results also showed that the calibration curve had great fitness for each dataset. More importantly, the decision curve suggested that the proposed nomogram model had a prominent clinical significance.

CONCLUSION

The nomogram model can be used as a risk assessment tool to reduce the missed diagnosis rate and the incidence of CRT in hospitalized children.

WHAT IS KNOWN

• Central venous access device-related thrombosis is generally asymptomatic for hospitalized children, causing the missed diagnosis of central venous access device-related thrombosis easily. • No risk prediction nomogram model for central venous access device-related thrombosis in hospitalized children has been established.

WHAT IS NEW

• A visual and personalized nomogram model was built by seven accessible variables (blind catheterization, abnormal liver function, central line-associated bloodstream infection, infection, number of catheter lines, leukemia, and bed rest > 72 h). • The model can effectively predict the risk of central venous access device-related thrombosis for hospitalized children.

Prevalence and Risk Factors of Deep Vein Thrombosis Among Adult Surgical Patients in Aseer Central Hospital, Saudi Arabia

INTRODUCTION

Deep vein thrombosis (DVT) is a medical disorder that arises when a coagulation of blood forms in a deep vein, entirely or partially blocking veins, and commonly affects the lower limb. The occurrence is fairly common worldwide and it is said to increase with age, with males being at a higher risk than females.

OBJECTIVE

This study aims to determine the prevalence and risk factors of DVT among adult surgical patients in Aseer Central Hospital in the Aseer Region of Saudi Arabia.

METHODS

This is a cross-sectional study involving 602 adult surgical patients hospitalized in the Aseer Central Hospital. Self-administered questionnaires were used to collect data from the respondents, and the data collected were analyzed using IBM SPSS Statistics for Windows, Version 24.0 (Released 2016; IBM Corp., Armonk, New York, United States). Statistical tests of association were used among the categorical variables. Association between variables was considered significant when p-value was less than 0.05. Binary logistic regression was performed to eliminate the effect of confounders in determining the risk factors for developing DVT among the respondents.

RESULTS

The questionnaire response rate was 100%, with the mean age of the respondents being 44.2 ± 19.7 years. The prevalence of DVT was 7% (n=42). Obesity with adjusted OR (aOR) 17.9 (95%CI =5.39-59.18), hypertension with aOR 0.3 (95%CI =0.08-1.03), ischemic heart disease with aOR4.5 (95%CI =1.18-16.83), and orthopedics aOR 0.1 (95%CI=0.013-.240) were found to be independent risk factors for developing DVT among the respondents (p-value <=0.05). Other variables like diabetes, contraception, and pregnancy were not statistically associated with the development of DVT (p-value> 0.05) in these respondents.

CONCLUSION

The findings of this study indicated a significantly low prevalence in comparison to Saudi Arabian research. Key risk factors included obesity (18x higher risk), ischemic heart disease, and hypertension. Surgery location, orthopedic cast, and Doppler ultrasound also influenced risk, while age and sex weren't significant predictors.

Ultrasound-guided supraclavicular cannulation of left brachiocephalic versus right internal jugular vein: Comparative analysis of central venous catheter-associated complications

AIMS

Central venous catheters are essential for the management of pediatric cardiac surgery patients. Recently, an ultrasound-guided access via a supraclavicular approach to the brachiocephalic vein has been described. Central venous catheters are associated with a relevant number of complications in pediatric patients. In this study, we evaluated the frequency of complications of left brachiocephalic vein access compared with right internal jugular vein standard access in children undergoing cardiac surgery.

METHODS

Retrospective analysis of all pediatric cases at our tertiary care university hospital over a two-year period receiving central venous catheters for cardiac surgery.

PRIMARY ENDPOINT

Frequency of complications associated with central venous catheters inserted via the left brachiocephalic vein vs. right internal jugular vein. Complications were defined as: chylothorax, deep vein thrombosis, sepsis, or delayed chest closure. Secondary endpoints: Evaluation of the insertion depth of the catheter using a height-based formula without adjustment for side used.

RESULTS

Initially, 504 placed catheters were identified. Following inclusion and exclusion criteria, 480 placed catheters remained for final analysis. Overall complications were reported in 68/480 (14.2%) cases. There was no difference in the frequency of all complications in the left brachiocephalic vein vs. the right internal jugular vein group (15.49% vs. 13.65%; OR = 1.16 [0.64; 2.07]), nor was there any difference considering the most relevant complications chylothorax (7.7% vs. 8.6%; OR = 0.89 [0.39; 1.91]) and thrombosis (5.6% vs. 4.5%; OR = 1.28 [0.46; 3.31]). The mean deviation from the optimal insertion depth was left brachiocephalic vein vs. right internal jugular vein 5.38 ± 13.6 mm and 4.94 ± 15.1 mm, respectively.

CONCLUSIONS

Among children undergoing cardiac surgery, there is no significant difference between the supraclavicular approach to the left brachiocephalic vein and the right internal jugular vein regarding complications. For both approaches, a universal formula can be used to determine the correct insertion depth.

Right Atrial Lines as Primary Access for Postoperative Pediatric Cardiac Patients

To characterize the use of right atrial lines (RALs) as primary access in the postoperative care of neonatal and pediatric patients after cardiothoracic surgery and to identify risk factors associated with RAL complications. Observational retrospective cohort study in pediatric cardiac patients who underwent RAL placement in a tertiary children's hospital from January 2011 through June 2018. A total of 692 children with congenital heart disease underwent 815 RAL placements during the same or subsequent cardiothoracic surgeries during the study period. Median age and weight were 22 days (IQR 7-134) and 3.6 kg (IQR 3.1-5.3), respectively. Neonates accounted for 53.5% of patients and those with single-ventricle physiology were 35.4%. Palliation surgery (shunts, cavo-pulmonary connections, hybrid procedures, and pulmonary artery bandings) accounted for 38%. Survival to hospital discharge was 95.5%. Median RAL duration was 11 days (IQR 7-19) with a median RAL removal to hospital discharge time of 0 days (IQR 0-3). Thrombosis and migration were the most prevalent complications (1.7% each), followed by malfunction (1.4%) and infection (0.7%). Adverse events associated with complications were seen in 12 (1.4%) of these RAL placements: decrease in hemoglobin (n = 1), tamponade requiring pericardiocentesis (n = 3), pleural effusion requiring chest tube (n = 2), and need for antimicrobials (n = 6). Multivariable logistic regression showed that RAL duration (OR 1.01, p = 0.006) and palliation surgery (OR 2.38, p = 0.015) were significant and independent factors for complications. The use of RALs as primary access in postoperative pediatric cardiac patients seems to be feasible and safe. Our overall incidence of complications from prolonged use of RALs remained similar or lower to that reported with short-term use of these lines. While RAL duration and palliation surgeries seemed to be associated with complications, severity of illness could be a confounding factor. A prospective assessment of RAL complications may improve outcomes in this medically complex population.

Transthoracic intracardiac lines-A double edged sword

OBJECTIVE

Routine use of central venous access is needed in children undergoing open heart surgery for pressure monitoring and inotrope infusion. We sought to evaluate the efficiency and safety of routine use of transthoracic intracardiac lines (ICLs) in patients undergoing cardiac surgery and to compare them to patients who have been previously treated with traditional central venous lines (non-ICLs).

METHODS

Retrospective review of charts of all patients who underwent cardiac surgery and had an ICL inserted in the operating room. Case control matching was done with similar patient in which ICL was not inserted. Patients characteristics, diagnosis, operative, and intensive care data were collected for each patient and analyzed.

RESULTS

A total number of 376 patient records were reviewed (198 ICL patients and 178 non-ICL patients). Umbilical line and non-ICL durations were longer in the non-ICL group. ICL duration was the longest of all lines, averaging 12.87 ± 10.82 days. The necessity for multiple line insertions (˃2 insertions) was significantly higher in the non-ICL group, with a relative risk ratio of 3.24 (95% confidence interval: 1.617-6.428). There was no statistical difference of infections rate and line complications between the two groups.

CONCLUSION

ICLs are safe in infants undergoing cardiac surgery and can be kept in place for a long period of time with a low rate of line complications and infection. Routine use of ICLs reduces the number of central venous catheter placement in this complex patient population.

Functional status of pediatric patients after extracorporeal membrane oxygenation: A five-year single-center study

OBJECTIVE

Extracorporeal membrane oxygenation (ECMO) is a widely used treatment for circulatory and pulmonary support in newborns and young children. Over the past decade, the number of children successfully treated with ECMO has gradually increased. However, despite an increasing number of survivors, new morbidity and long-term health issues are becoming more prevalent. A better understanding of the pediatric ECMO prognosis contributes to improved treatment and care programs and minimizes the risk of sequelae and dysfunctions. We aimed to determine the incidence of new morbidity, prognoses, and follow-up data of survivors treated with ECMO in pediatric intensive care units (PICU) using the Functional Status Scale (FSS).

METHODS

We retrospectively collected and analyzed clinical data of patients in the PICU who received ECMO from January 2016 to January 2020. Clinical and functional outcomes were assessed at admission and discharge using the FSS. Twenty-seven patients aged between 1 month and 14 years who received ECMO in the PICU were included. Fifty-two percent were male, and the median age was 36 months (interquartile range, 21-114 months). The patients were admitted for fulminant myocarditis (n = 13), acute respiratory distress syndrome (ARDS) (n = 11), and septic shock (n = 3).

RESULTS

This study reviewed a single-center experience using the FSS for ECMO treatment in a PICU. The patients' original conditions included fulminant myocarditis, ARDS, and septic shock. Of the 27 patients who received ECMO, 9 (33%) died, 12 (67%) showed improved condition, and 6 (33%) discontinued treatment and left the hospital. Furthermore, the following adverse events were observed in the survivors who were discharged: nine (50%) cases of lower extremity deep vein thrombosis, seven (39%) jugular vein thrombosis, six (33%) acute kidney injury, five (27%) intracranial hemorrhage and cerebral infarction, and one each of (6% each) pulmonary embolism and peripheral nerve injury. Of the 12 patients who survived through 1 year after discharge, five (42%) recovered completely, whereas seven (58%) showed mild to moderate communication and motor dysfunction. The short-term survival rate and 1-year survival rate of ECMO patients were 67% (18/27) and 44% (12/27), respectively. Additionally, approximately one-third of the patients developed a new morbidity after ECMO treatment (6/18).

CONCLUSIONS

High mortality and new morbidity were common in patients who received ECMO treatment. New morbidity increased the risk of death and exacerbated the functional state. Follow-up and rehabilitation after discharge are essential to achieve positive outcomes.

The Utility of Point-of-Care Ultrasound in the Pediatric Intensive Care Unit

Objectives: Point of care ultrasound (POCUS) in adult critical care environments has become the standard of care in many hospitals. A robust literature shows its benefits for both diagnosis and delivery of care. The utility of POCUS in the pediatric intensive care unit (PICU), however, is understudied. This study describes in a series of PICU patients the clinical indications, protocols, findings and impact of pediatric POCUS on clinical management. Design: Retrospective analysis of 200 consecutive POCUS scans performed by a PICU physician. Patients: Pediatric critical care patients who required POCUS scans over a 15-month period. Setting: The pediatric and cardiac ICUs at a tertiary pediatric care center. Interventions: Performance of a POCUS scan by a pediatric critical care attending with advanced training in ultrasonography. Measurement and Main Results: A total of 200 POCUS scans comprised of one or more protocols (lung and pleura, cardiac, abdominal, or vascular diagnostic protocols) were performed on 155 patients over a 15-month period. The protocols used for each scan reflected the clinical question to be answered. These 200 scans included 133 thoracic protocols, 110 cardiac protocols, 77 abdominal protocols, and 4 vascular protocols. In this series, 42% of scans identified pathology that required a change in therapy, 26% confirmed pathology consistent with the ongoing plans for new therapy, and 32% identified pathology that did not result in initiation of a new therapy. Conclusions: POCUS performed by a trained pediatric intensivist provided useful clinical information to guide patient management.

Thromboembolic Complications of Vascular Catheters Used for Pediatric Continuous Renal Replacement Therapy: Prevalence in a Single-Center, Retrospective Cohort

OBJECTIVES

Pediatric venous thromboembolic events are commonly associated with in situ central venous catheters. The risk for severe venous thromboembolism increases if a larger portion of the vessel lumen is occupied by the central venous catheter. A functioning vascular catheter is required when the continuous renal replacement therapy is used in critically ill children. Due to the high blood flow required for continuous renal replacement therapy, the external diameter of the catheter needs to be larger than a conventional central venous catheter used for venous access, potentially increasing the risk of venous thromboembolism. However, children on continuous renal replacement therapy often receive systemic anticoagulation to prevent filter clotting, possibly also preventing venous thromboembolism. The frequency of catheter-related venous thromboembolic events in this setting has not been described. Our main objective was to determine the prevalence of catheter-related venous thromboembolism in pediatric continuous renal replacement therapy.

DESIGN

Retrospective cohort study.

SETTING

Tertiary multidisciplinary academic pediatric hospital.

PATIENTS

Patients 0-18 years old with a vascular catheter used for continuous renal replacement therapy.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In our series of 80 patients, we used 105 vascular catheters. The median age of the patients was 10 months and PICU mortality rate was 21%. Venous thromboembolic events were considered to be catheter related if located in the same vein as the vascular catheter and radiologically verified. Six (5.7%) catheter-related venous thromboembolic events were found. The clinically relevant complications of venous thromboembolism included superior vena cava syndrome and catheter dysfunction. In one patient, severe and life-threatening pulmonary embolism occurred. In comparison with patients without venous thromboembolism, venous thromboembolic events were associated with lower body weight (p = 0.03) and longer durations of continuous renal replacement therapy (p < 0.01), mechanical ventilation (p = 0.03), and PICU stay (p < 0.01). Five out of six venous thromboembolisms appeared in neonates.

CONCLUSIONS

Catheter-related venous thromboembolism is a clinically relevant complication of pediatric continuous renal replacement therapy, with a prevalence of 5.7% in our cohort. Clinicians involved in pediatric continuous renal replacement therapy need to be vigilant for symptoms of venous thromboembolisms and initiate appropriate treatment as soon as possible.

A retrospective cohort study of disease-related risk factors for central venous catheter-related symptomatic thrombosis in intensive care unit inpatients

Central venous catheters (CVC) are widely used in critically ill patients given their benefits in monitoring vital signs, treatment administration, and renal replacement therapy in intensive care unit (ICU) patients, but these catheters have the potential to induce symptomatic catheter-related venous thrombosis (CRVT). This study reported the rate of symptomatic CRVT in ICU patients receiving CVC and analyzed the disease-related risk factors for symptomatic CRVT in ICU patients.A retrospective analysis was performed on the consecutive ICU 1643 critically ill patients with CVCs inserted from January 2015 to December 2019. Symptomatic CRVT was confirmed by ultrasound. CVCs were divided into 2 groups based on the presence of symptomatic CRVT, and the variables were extracted from the electronic medical record system. Logistic univariate and multivariate regression analyses were used to determine the disease-related risk factors of symptomatic CRVT.A total of 209 symptomatic CRVT events occurred among 2114 catheters. The rate of CRVT was 9.5 per 1000 catheter days. Univariate analysis revealed that trauma, major surgery, heart failure, respiratory failure, and severe acute pancreatitis were risk factors for symptomatic CRVT in the ICU. Multivariate analysis showed that trauma (odds ratio [OR], 2.046; 95% confidence interval [CI] [1.325-3.160], P = .001), major surgery (OR, 2.457; 95% CI [1.641-3.679], P = .000), and heart failure (OR, 2.087; 95% CI [1.401-3.111], P = .000) were independent disease-related risk factors for symptomatic CRVT in ICU. The C-statistic for this model was 0.61 (95% CI [0.57-0.65], P = .000).The incidence rate of symptomatic CRVT in the ICU population was 9.5 per 1000 catheter days. Trauma, major surgery, and heart failure are independent disease-related risk factors of symptomatic CRVT.

Venous Thromboembolism among Critically Ill Children: A Narrative Review

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality among hospitalized patients, including children. In recent years, it has become clear that hospitalization and critical illness bestow an increased VTE risk in pediatrics and relate to mortality and life-limiting comorbidities. For critically ill children, reported rates of VTE vary by study sampling techniques, presence of inherited or acquired thrombophilia, acute and chronic immobility, underlying illness prompting hospitalization, and clinical factors related to illness severity such as central venous catheterization, length of stay, mechanical ventilation, and patient age. Accordingly, critically ill children with new signs of venous congestion, acute inflammation, or unexplained acute organ dysfunction should be routinely evaluated for VTE. This narrative review summarizes recent and historical literature regarding risk factors, prevention, presentation, treatment, and outcomes of VTE in critically ill children. In addition, we identify knowledge gaps and priorities for future collaborative research on this vital condition. Special attention is given to the clinical trial opportunities, challenges, and ongoing efforts in thromboprophylaxis in critically ill children, including those hospitalized for disease related to novel coronavirus (COVID-19) and multisystem inflammatory disease in children.

Enoxaparin Reduces Catheter Associated Venous Thrombosis Following Infant Cardiac Surgery

BACKGROUND

Central venous catheter (CVC) related venous thrombosis (VT) following pediatric cardiac surgery increases the morbidity and mortality. Although VT prevention using low dose anticoagulation has proven ineffective, anticoagulation using high dose enoxaparin to achieve a therapeutic anti-xa level has not been studied. We hypothesized that high dose enoxaparin would reduce VT after pediatric cardiac surgery.

METHODS

Enoxaparin was administered to infants < 150 days when post-operative CVC duration was anticipated to extend beyond 5 days. The primary outcome was the rate of VT, re-exploration for bleeding, and post-operative red blood cell (RBC) transfusions per 1,000 CVC days.

RESULTS

From 2012-2019, 157 infants were treated with enoxaparin. Infants were divided into two groups: 1) SubTherapeutic (SubTher) (N = 51) - therapeutic anti-xa level (0.5-1.0 IU/mL) was not achieved, 2) Therapeutic (Ther) (N = 106) - therapeutic anti-xa level was achieved. Baseline demographics demonstrated a lower age at operation within the Ther group. The SubTher group had a higher VT rate/1,000 CVC days (8.2) compared to the Ther group (2.6; p=0.005). Re-exploration for bleeding was similar between groups. The number of post-operative RBC transfusions/1,000 CVC days was significantly greater in the SubTher group (109.4 vs. 81.6; p=0.008). Multivariate analysis demonstrated that higher median anti-xa levels reduced the risk of VT (OR 0.02, CI: 0.001, 0.63; p = 0.02).

CONCLUSIONS

This data suggests that enoxaparin treatment resulting in a therapeutic anti-xa level reduces post-operative CVC associated VT without increasing bleeding complications.

Inpatient dental consultations at a pediatric hospital: A single center 1-year review

AIMS

Inpatient dental consultations done at a pediatric hospital in 2017 were analyzed to determine consult reasons, requesting departments, and patient characteristics. Findings were compared to a 2007 study from the hospital.

METHODS AND RESULTS

Data were collected from medical records. Descriptive statistics and logistic regressions were calculated. In 2017, 300 consults were performed for 211 patients (1.8% of inpatients). hematology-oncology requested the most consults (63%). Evaluation prior to cancer treatment, cardiac surgery, or organ transplantation was the most common reason for consult requests (52%). Fifty-eight percent patients had a dental home; older patients were more likely to have a dental home (P < .001). Patients with a dental home were less likely to have caries (P = .047). Many patients with a dental home had caries (33% in 2007 and 29% in 2017); more patients without a dental home had caries (46% in 2007 and 38% in 2017).

CONCLUSIONS

This study both supports the dental home concept and reveals that many children with a dental home have treatment needs. This indicates that medical providers should not equate having a dental home with having dental health and emphasizes the value of an in-hospital dental service to support the management of critically ill children.

Dexmedetomidine Attenuates Monocyte-Endothelial Adherence via Inhibiting Connexin43 on Vascular Endothelial Cells

Current studies have identified the multifaceted protective functions of dexmedetomidine on multiple organs. For the first time, we clarify effects of dexmedetomidine on monocyte-endothelial adherence and whether its underlying mechanism is relative to connexin43 (Cx43), a key factor regulating monocyte-endothelial adherence. U937 monocytes and human umbilical vein endothelial cells (HUVECs) were used to explore monocyte-endothelial adherence. Two special siRNAs were designed to knock down Cx43 expression on HUVECs. U937-HUVEC adhesion, adhesion-related molecules, and the activation of the MAPK (p-ERK1/2, p-p38, and p-JNK1/2) signaling pathway were detected. Dexmedetomidine, at its clinically relevant concentrations (0.1 nM and 1 nM), was given as pretreatments to HUVECs. Its effects on Cx43 and U937-HUVEC adhesion were also investigated. The results show that inhibiting Cx43 on HUVECs could attenuate the contents of MCP-1, soluble ICAM-1 (sICAM-1), soluble VCAM-1 (sVCAM-1), and the nonprocessed variants of the adhesion molecules ICAM-1 and VCAM-1 and ultimately result in U937-HUVEC adhesion decrease. Meanwhile, the activation of MAPKs was also inhibited. U0126 (inhibiting p-ERK1/2) and SB202190 (inhibiting p38) decreased the contents of MCP-1, sICAM-1, and sVCAM-1, but SP600125 (inhibiting p-JNK1/2) had none of these effects. ICAM-1 and VCAM-1 could be regulated in a similar way. Dexmedetomidine pretreatment inhibited Cx43 on HUVECs, the activation of MAPKs, and U937-HUVEC adhesion. Therefore, we conclude that dexmedetomidine attenuates U937-HUVEC adhesion via inhibiting Cx43 on HUVECs modulating the activation of MAPK signaling pathways.