Incidence and risk factors of subclinical umbilical catheter-related thrombosis in neonates

Association between Portal Vein Thrombosis after Umbilical Vein Catheterization and Neonatal Asphyxia

INTRODUCTION

Neonatal portal vein thrombosis (PVT) is frequently related to umbilical venous catheterization (UVC), but risk factors remain unclear. This study aims to analyze the variables associated to PVT in near- to full-term newborns with UVC, with a focus on newborns exposed to controlled therapeutic hypothermia (CTH) for hypoxic ischemic encephalopathy (HIE).

METHODS

This is retrospective cohort study of infants delivered at or after 36 weeks and with a birthweight over 1,500 g. All infants were assessed for UVC location and PVT using ultrasonography performed between day 5 and day 10 after catheterization.

RESULTS

Among 213 eligible patients, PVT was diagnosed in 57 (27%); among them, 54 (95%) were localized in the left portal vein branch. With all significant factors in univariate analysis considered, higher gestational age at birth (adjusted OR 1.35; 95% CI: 1.12-1.64, p = 0.002) and duration of UVC placement (adjusted OR 1.36; 95% CI: 1.11-1.67, p = 0.004) were the main risk factors of PVT. Among 87 infants who were cooled for HIE, 31 (36%) had PVT compared to 26 (21%) in infants without CTH. Using a multivariate model including variables linked to treatment procedures only, an increased PVT incidence was statistically associated with UVC duration (adjusted OR 1.33; 95% CI: 1.08; 1.63, p = 0.01) and CTH (adjusted OR 1.94; 95% CI: 1.04-3.65, p = 0.04).

CONCLUSION

Left PVT was frequently observed in near- to full-term neonates with UVC. Among factors linked to treatment procedures, both duration of UVC and CTH exposure for HIE were found to be independent risk factors of PVT.

Modern Aspects of Anticoagulation System Disorders Diagnosis in Children with Different Polymorphisms in Coagulation Genes. Initial Results

Background. Hemostatic system pathology is topical and poorly studied issue in pediatrics. One of the main causes of coagulation pathway disorders associated with thrombotic events is abnormality in various parts of the hemostatic system. Vascular accidents are commonly caused by anticoagulation system factors deficiency. Conventionally, thrombosis is a common event in adult patients, and there is no adequate attention to disorders of primary physiological anticoagulants system in children. More often acquired anticoagulant proteins deficiency develops in presence of various pathological conditions, especially after the past infectious diseases. All these diseases (thrombophilia, trombotic events, cardiovascular pathology, nervous system diseases, genetic diseases) can occur separately and in association with each other, plus clinical picture of coagulation events may be similar. Objective. The aim of the study is to evaluate changes in the physiological anticoagulants system in children with different pathologies who have polymorphic variants in coagulation genes and who had new coronavirus infection. Methods. The study included 33 children who had severe coronavirus infection in family clusters and had severe chronic pathology potentially associated with disorders of the coagulation system (nervous system damage, hypertrophic cardiomyopathy, hereditary monogenic syndromes, hemato-mesenchymal dysplasia syndrome). All children underwent complete examination including clinical examination, laboratory, and instrumental diagnostics. Results. Preliminary study results indicate significant incidence of polymorphic variants in coagulation genes (one third of children with various diseases from the study). Some children had decreased activity of anticoagulation system glycoproteins (from 6% to 36%) that confirmed the topicality of the examination of anticoagulation system factors deficiency and the need for further dynamic follow-up, as well as revealing of trombophilia predictors in children in selected target groups. Study on revealing anticoagulation system disorders and mutations in coagulation genes will predict the risk of thrombotic disorders. Conclusion. The obtained results have confirmed the significant role of the ongoing study for comprehensive assessment of hemostatic system disorders in children. That will allow us to optimize the approach to diagnosis and personalize the management strategy for patients with different chronic pathologies and disorders of the natural anticoagulants system. The study is currently ongoing.

Incidence of umbilical vein catheter-associated thrombosis of the portal system: A systematic review and meta-analysis

BACKGROUND

The use of umbilical venous catheters (UVCs) in the perinatal period may be associated with severe complications, including the occurrence of portal vein thrombosis (PVT).

AIM

To assess the incidence of UVC-related PVT in infants with postnatal age up to three months.

METHODS

A systematic and comprehensive database searching (PubMed, Cochrane Library, Scopus, Web of Science) was performed for studies from 1980 to 2020 (the search was last updated on November 28, 2020). We included in the final analyses all peer-reviewed prospective cohort studies, retrospective cohort studies and case-control studies. The reference lists of included articles were hand-searched to identify additional studies of interest. Studies were considered eligible when they included infants with postnatal age up to three months with UVC-associated PVT. Incidence estimates were pooled by using random effects meta-analyses. The quality of included studies was assessed using the Newcastle-Ottawa scale. The systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines.

RESULTS

Overall, 16 studies were considered eligible and included in the final analyses. The data confirmed the relevant risk of UVC-related thrombosis. The mean pooled incidence of such condition was 12%, although it varied across studies (0%-49%). In 15/16 studies (94%), diagnosis of thrombosis was made accidentally during routine screening controls, whilst in 1/16 study (6%) targeted imaging assessments were carried out in neonates with clinical concerns for a thrombus. Tip position was investigated by abdominal ultrasound (US) alone in 1/16 (6%) studies, by a combination of radiography and abdominal US in 14/16 (88%) studies and by a combination of radiography, abdominal US and echocardiography in 1/16 (6%) studies.

CONCLUSION

To the best of our knowledge, this is the first systematic review specifically investigating the incidence of UVC-related PVT. The use of UVCs requires a high index of suspicion, because its use is significantly associated with PVT. Well-designed prospective studies are required to assess the optimal approach to prevent UVC-related thrombosis of the portal system.

Adverse events associated with umbilical catheters: a systematic review and meta-analysis

OBJECTIVE

To determine the incidence of adverse events (AEs) associated with umbilical catheters in the neonatal population.

STUDY DESIGN

Systematic review and meta-analysis of observational studies and randomized controlled trials published between 2010 and 2020.

RESULTS

In total 14,226 umbilical venous catheters (UVCs) and 4228 umbilical arterial catheters (UACs) were included. Overall, 13.4% of UVCs were associated with an AE (95% CI: 10.1-17.0) or 2.4 per 1000 catheter days (95% CI: 1.8-3.0). UACs had an AE rate of 9% (95% CI: 5.9-12.8) or 0.87 per 1000 catheter days (95% CI: 0.4-1.3). UVC malposition was the most common (41.7% [95% CI: 27.6-56.5]). Local injury from UAC taping was the most common AE in one study.

CONCLUSIONS

Umbilical catheters have a high incidence of AEs. Research into accurate methods of tip verification, tip surveillance, and securement is required.

Venous thrombosis in neonates

The incidence of thrombotic disorders in neonates and children is increasing with advances in diagnostic modalities, supportive care, and management of many health conditions. The developing coagulation system, need for intensive care, including catheterization, and co-morbid conditions are responsible for the relatively high risk of thrombosis in neonates compared to older children. This review addresses the advances over the last 3 years in neonatal thrombosis, with a focus on epidemiology, cerebral sinovenous thrombosis (CSVT), renal vein thrombosis (RVT), and portal vein thrombosis (PVT). The incidence of neonatal thrombosis in the contemporary era is reported to be 6.9-15 per 1,000 neonatal intensive care unit (NICU) admissions, compared to 2.4 per 1,000 NICU admissions reported in older registry data. The majority of recently published studies are small, retrospective, and from single centers, albeit they emphasize the need for definitive data to support the efficacy and safety of anticoagulation therapy (ACT) in the management of CSVT, RVT, and PVT. We highlight two important international initiatives geared towards improving the evidence base for these conditions. The International Pediatric Thrombosis Network (IPTN) is a collaboration of 74 centers across 27 countries (as of January 2021) which has started important projects like the international neonatal RVT registry, while the International Pediatric Stroke Study (IPSS) group is in the planning stages of a randomized controlled trial to evaluate the utility of ACT in the management of neonatal CSVT.