IV enoxaparin in pediatric and cardiac ICU patients

Questions around a case of in utero thrombosis in a premature child, concerning the management of anticoagulant treatments

We report the case of a preterm infant presenting a thrombosis, discovered on ultrasound at 22 weeks of gestational age and confirmed at birth following additional examinations. We describe the anticoagulant treatment of this patient by intravenous enoxaparin, tinzaparin and rivaroxaban, from questioning to practice.

Retrospective Evaluation of Intravenous Enoxaparin Administration in Feline Arterial Thromboembolism

Simple Summary

Feline arterial thromboembolism is a painful disease characterized by acute ischemic necrosis of one or more limbs due to cardiac diseases, hyperthyroidism, or neoplasia. Among others, medical treatment consists of preventing new thrombus formation primarily using heparin products, such as enoxaparin. This retrospective study reports clinical data, regain of perfusion, short-term outcome, and complications of 36 affected cats treated with a novel intravenous enoxaparin protocol. Furthermore, we aimed to report monitoring and management of the intravenous enoxaparin treatment for this disease. In our population, visible hemorrhage was rare. The most common causes of death/euthanasia were cardiac instability, acute kidney injury, neurological abnormalities, and limb necrosis. The hospital discharge rate was 47% overall and was significantly different between single limb (83%) and dual limb (29%) thromboembolism. Our study supports the intravenous use of enoxaparin in combination with oral clopidogrel for cats with thromboembolism as an alternative treatment method.

Abstract

Induction of a hypocoagulable state is imperative in the treatment of feline arterial thromboembolism. Publications in human medicine report the use of enoxaparin intravenously in selected cases. The aim of our retrospective study was to report the regain of perfusion, short-term outcome, and complications of cats treated with a novel intravenous enoxaparin protocol (1 mg/kg bolus injection followed by 3 mg/kg/day continuous infusion) combined with oral clopidogrel administration. The secondary aim was to report the monitoring of enoxaparin with anti-Xa activity. There were 36 cats included. The probability of reaching limb reperfusion was significantly (p = 0.0148) higher with anti-Xa activity within or above the target range compared to results below the target range (19/21, 90% versus 11/20, 55%). The complications observed were acute kidney injury (15/36, 42%), hemorrhage (2/36, 6%), and neurological signs (6/36, 17%). The most common causes of death/euthanasia were cardiac instability, acute kidney injury, neurological abnormalities, and limb necrosis. The hospital discharge rate was 83% (10/12) for single limb and 29% (7/24) for dual limb thrombosis; the difference was significant (p = 0.0039). The median hospitalization time for the survivors was 119.5 (95–480) h. Our study supports the use of intravenous continuous rate infusion of enoxaparin in combination with oral clopidogrel for cats with aortic thromboembolism. We report similar discharge rates and lower hemorrhage rates than previously reported with thrombolytic treatment.

PICU Pharmacology

The care of the critically-ill child often includes medications used to optimize organ function, treat infections, and provide comfort. Pediatric pharmacology has some key differences that should be leveraged for safe pharmacologic management.

How to use low-molecular-weight heparin to treat neonatal thrombosis in clinical practice

Among children, neonates have the highest incidence of thrombosis due to risk factors such as catheter instrumentation, an evolving coagulation system and congenital heart disease. Low-molecular-weight heparins (LMWHs) are the most commonly used anticoagulants in neonates. Published guidelines delineate dosing and monitoring protocols for LMWH therapy in newborns. However, challenging clinical situations frequently present that warrant healthcare providers to think critically beyond the range of guidelines, and judiciously resolve specific problems. This review describes the use of LMWH in the neonatal population, including practical aspects such as route and site of administration, preparation from concentrated formulations and methods to minimize pain of subcutaneous injection. It is followed by a discussion on dosing, monitoring and outcomes of LMWH therapy in neonates. The risk of recurrence of thrombosis in neonates after LMWH therapy is approximately 3% based on a pooled analysis of studies reporting this outcome over the last 24 years. The article concludes with an overview of the side-effects of LMWH, including the risk of bleeding which is around 4% based on pooled analyses of more than 30 studies.

The Trilogy of SARS-CoV-2 in Pediatrics (Part 3): Thrombosis, Anticoagulant, and Antiplatelet Considerations

The hypercoagulable state induced by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) affects all patients regardless of age. The incidence of venous thromboembolism in pediatric patients with SARS-CoV-2-related illnesses is not well established. Although deep vein thrombosis is rare in children in the absence of risk factors, coagulopathy and the development of thromboses have been described in pediatric patients with acute COVID-19 and multisystem inflammatory syndrome. This comprehensive review provides a detailed overview of SARS-CoV-2-associated coagulopathy as well as strategies for optimizing the evaluation, management, and prevention of thrombosis in pediatric patients.

Intravenous Enoxaparin in Pediatric Burn Patients: A Case Series

Patients with acute burns experience a hypercoagulable state that may necessitate the use of anticoagulants to prevent the complications of venous thromboembolism (VTE). Enoxaparin is a low molecular weight heparin that is commonly used for this purpose; however, the traditional SC route of administration poses potential limitations in the pediatric burn population. These include pain upon injection, increased anxiety, erroneous absorption and distribution, and difficulty in finding an administration site when burns encompass a large percentage of body surface area. As a result, the IV route of administration may be preferable in these patients. To date, a limited number of studies in critically ill pediatric patients have been performed. In this report, we present a case series of 3 pediatric burn patients who initially received SC enoxaparin and were transitioned to IV enoxaparin for VTE prophylaxis. The patients were 2, 8, and 10 years old. Burn involvement ranged from 8% to 75% total body surface area, and all patients had central line access. Adequate prophylactic low molecular weight heparin anti-Xa peak concentrations (0.1-0.3 international units/mL) were achieved with IV doses ranging from 0.35 to 0.5 mg/kg administered every 12 hours. No adverse effects, major bleeding events, or treatment failures occurred.

IV Versus Subcutaneous Enoxaparin in Critically Ill Infants and Children: Comparison of Dosing, Anticoagulation Quality, Efficacy, and Safety Outcomes

OBJECTIVE

Subcutaneous enoxaparin is the mainstay anticoagulant in critically ill pediatric patients although it poses several challenges in this patient population. Enoxaparin infused IV over 30 minutes represents an attractive alternative, but there is limited experience with this route of administration in children. In this study, we assess dosing, anticoagulation quality, safety, and clinical efficacy of IV enoxaparin compared to subcutaneous enoxaparin in critically ill infants and children.

DESIGN

Retrospective single-center study comparing dosing, anticoagulation quality, safety, and clinical efficacy of two different routes of enoxaparin administration (IV vs subcutaneous) in critically ill infants and children. Key outcome measures included dose needed to achieve target antifactor Xa levels, time required to achieve target antifactor Xa levels, proportion of patients achieving target anticoagulation levels on initial dosing, number of dose adjustments, duration spent in the target antifactor Xa range, anticoagulation-related bleeding complications, anticoagulation failure, and radiologic response to anticoagulation.

SETTING

Tertiary care pediatric hospital.

PATIENTS

All children admitted to the cardiac ICU, PICU, or neonatal ICU who were prescribed enoxaparin between January 2014 and March 2016 were studied.

INTERVENTIONS

One hundred ten patients were identified who had received IV or subcutaneous enoxaparin and had at least one postadministration peak antifactor Xa level documented.

MEASUREMENTS AND MAIN RESULTS

Of the 139 courses of enoxaparin administered, 96 were therapeutic dose courses (40 IV and 56 subcutaneous) and 43 were prophylactic dose courses (20 IV and 23 subcutaneous). Dosing, anticoagulation quality measurements, safety, and clinical efficacy were not significantly different between the two groups.

CONCLUSIONS

Our study suggests that anticoagulation with IV enoxaparin infused over 30 minutes is a safe and an equally effective alternative to subcutaneous enoxaparin in critically ill infants and children.