Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Anticoagulation and Thrombolysis

Just DOAC: Use of direct-acting oral anticoagulants in pediatrics

PURPOSE

The aim of this article is to provide an overview of the current literature for direct-acting oral anticoagulant (DOAC) use in pediatric patients and summarize ongoing trials.

SUMMARY

In treatment of venous thromboembolism (VTE) in pediatric patients, evidence supports use of both dabigatran and rivaroxaban. Dabigatran has been shown to be noninferior to standard of care (SOC) in terms of efficacy, with similar bleeding rates. Similarly, treatment with rivaroxaban in children with acute VTE resulted in a low recurrence risk and reduced thrombotic burden, without increased risk of bleeding, compared to SOC. Treatment of pediatric cerebral venous thrombosis as well as central venous catheter-related VTE with rivaroxaban appeared to be both safe and efficacious and similar to that with SOC. Dabigatran also has a favorable safety profile for prevention of VTE, and rivaroxaban has a favorable safety profile for VTE prevention in children with congenital heart disease. Many studies with several different DOACs are ongoing to evaluate both safety and efficacy in unique patient populations, as well as VTE prevention.

CONCLUSION

The literature regarding pediatric VTE treatment and prophylaxis is growing, but the need for evidence-based pediatric guidelines remains. Additional long-term, postauthorization studies are warranted to further elucidate safety and efficacy in clinical scenarios excluded in clinical trials. Additional data on safety, efficacy, and dosing strategies for reversal agents are also necessary, especially as the use of DOACs becomes more common in the pediatric population.

A Narrative Review of Postoperative Anticoagulation Therapy for Congenital Cardiac Disease

Congenital heart disease encompasses a range of cardiac birth defects. Some defects require early and complex surgical intervention and post-operative thromboprophylaxis primarily for valve, conduit, and shunt patency. Antiplatelet and anticoagulant management strategies vary considerably and may or may not align with recognized consensus practice guidelines. In addition, newer anticoagulant agents are being increasingly used in children, but these medications are not addressed in most consensus statements.

This narrative review evaluated the literature from 2011 through 2021 on the topic of postoperative thromboprophylaxis after congenital heart disease operations. The search was focused on the descriptions and results of pediatric studies for replacement and/or repair of heart valves, shunts, conduits, and other congenital heart disease operations. Wide variability in practice exists and, as was true a decade ago, few randomized controlled trials have been conducted. Aspirin, warfarin, and perioperative heparin remain the most commonly used agents with varying dosing, duration, and monitoring strategies, making comparisons difficult. Only recently have data on direct oral anticoagulants been published in children, suggesting evolving paradigms of care. Our findings highlight the need for more research to strengthen the evidence for standardized thromboprophylaxis strategies.

Venous Thromboembolism in Premature Neonates

While the incidence of venous thromboembolism (VTE) is lower among children than adults, the newborn period is one of two bimodal peaks (along with adolescence) in VTE incidence in the pediatric population. Most VTE cases in neonates occur among critically ill neonates being managed in the neonatal intensive care unit, and most of these children are born premature. For this reason, the presentation, diagnosis, management, and outcomes of VTE among children born premature deserve special emphasis by pediatric hematologists, neonatologists, pharmacists, and other pediatric health care providers, as well as by the scientific community, and are described in this review.

Outcomes of Catheter-Related Arterial and Venous Thrombosis After Enoxaparin Therapy in Neonates and Infants With Congenital Heart Disease

OBJECTIVES

Outcomes of catheter-related arterial and venous thrombosis after enoxaparin therapy in neonates and infants with congenital heart disease.

DESIGN

A single-center retrospective cohort study.

SETTING

Cardiac ICU.

PATIENTS

Patients under 1 year old cared for in the cardiac ICU at Nicklaus Children's Hospital from January 2015 to January 2019 and treated with enoxaparin for central vascular catheter-related arterial and venous thrombosis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One-hundred fifty-six events of central catheter-related arterial and venous thrombosis were included in the study. Arterial thrombi accounted for 109 (69.9%) and venous thrombi for 47 (30.1%) of the events. Femoral vessels were the most commonly affected site (88.5%). Therapeutic outcomes were analyzed in 106 events, excluding those without follow-up imaging. The analysis was stratified by age into neonates and infants and catheter types into arterial and venous catheter groups. Therapeutic dose of enoxaparin was higher in neonates (median 1.8 mg/kg/dose) compared with infants (1.6 mg/kg/dose; p = 0.001). Complete resolution was seen in 68%, partial resolution in 19%, nonresolution in 13% of the events. The complete resolution was higher for arterial than venous (85% vs 65.6%; p = 0.032) thrombi with a shorter duration of enoxaparin treatment (23 vs 43 d; p = 0.014). Complete resolution was lowest in neonates with venous thrombosis (42.9%). The median time to complete resolution by Kaplan-Meier analysis was 24.9 days in the overall cohort, 34.3 days in neonates, 24.9 days in infants, 20 days in arterial, and 44.9 days in venous catheter group.

CONCLUSIONS

A high proportion of vascular catheter-related thrombi identified in infants with congenital heart disease resolve with enoxaparin treatment. In all patients with thrombosis, arterial versus venous thrombosis is associated with greater odds of resolution.

Thrombosis Prevention and Anticoagulation Management in the Pediatric Patient with Congenital Heart Disease

Thrombosis is one of the most frequent complications affecting children with congenital heart disease (CHD). Palliative and reparative cardiac surgeries are some of the main players contributing to the thrombosis risk in this patient population. Additional risk factors related to the CHD itself (e.g., cardiac dysfunction, arrhythmias, and polycythemia in cyanotic cardiac disorders) can contribute to thrombogenicity alone or combined with other factors. Thrombotic complications have been recognized as a significant cause of morbidity and mortality in this patient population. Here, we provide an overview of the pathophysiology and risk factors for thrombosis as well as the indications for and use of different anticoagulation, antiplatelet, and thrombolytic agents. In addition, we describe some of most common thrombotic complications and their management in the pediatric CHD population.

Multisystem inflammatory syndrome associated with COVID-19 from the pediatric emergency physician's point of view

OBJECTIVE

Multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease (COVID-19) is a rare and challenging diagnosis requiring early treatment. The diagnostic criteria involve clinical, laboratory, and complementary tests. This review aims to draw pediatrician attention to this diagnosis, suggesting early treatment strategies, and proposing a pediatric emergency care flowchart.

SOURCES

The PubMed/MEDLINE/WHO COVID-19 databases were reviewed for original and review articles, systematic reviews, meta-analyses, case series, and recommendations from medical societies and health organizations published through July 3, 2020. The reference lists of the selected articles were manually searched to identify any additional articles.

SUMMARY OF THE FINDINGS

COVID-19 infection is less severe in children than in adults, but can present as MIS-C, even in patients without comorbidities. There is evidence of an exacerbated inflammatory response with potential systemic injury, and it may present with aspects similar to those of Kawasaki disease, toxic shock syndrome, and macrophage activation syndrome. MIS-C can develop weeks after COVID-19 infection, suggesting an immunomediated cause. The most frequent clinical manifestations include fever, gastrointestinal symptoms, rash, mucous membrane changes, and cardiac dysfunction. Elevated inflammatory markers, lymphopenia, and coagulopathy are common laboratory findings. Supportive treatment and early immunomodulation can control the intense inflammatory response and reduce complications and mortality.

CONCLUSIONS

MIS-C associated with COVID-19 is serious, rare, and potentially fatal. The emergency department pediatrician must recognize and treat it early using immunomodulatory strategies to reduce systemic injury. Further studies are needed to identify the disease pathogenesis and establish the most appropriate treatment.

The use of alteplase in a newborn with an aortic arch thrombus during extracorporeal membrane oxygenation

We report a neonatal case of the use of alteplase for the lysis of a large aortic arch thrombus formed during extracorporeal membrane oxygenation support. Alteplase (0.1-0.15 mg/kg/hour) was infused for thrombolysis, and meanwhile, unfractionated heparin was administrated at 5-10 U/kg/hour for the anticoagulation purpose. Alteplase was successfully administered to this neonate after the repair of congenital diaphragmatic hernia on extracorporeal membrane oxygenation, and the patient survived without apparent catastrophic long-term complications. It is reasonable to consider alteplase therapy during extracorporeal membrane oxygenation support in this setting.

Antiplatelet Effect of Ketorolac in Children After Congenital Cardiac Surgery

Background:

Ketorolac is used for pediatric analgesia after surgery despite its known platelet inhibition via the arachidonic acid (AA) pathway. The degree of platelet inhibitory effect after cardiac surgery is not well characterized. Thromboelastography with platelet mapping (TEG-PM) is emerging as a frequently used test to evaluate platelet inhibition via the AA pathway.

Methods:

Post hoc analysis of a data set collected in a prospective observational cohort study evaluating platelet inhibition in children after congenital heart surgery with cardiopulmonary bypass (CPB). Categorization into two groups: (1) received ketorolac and (2) did not receive ketorolac for analgesia after surgery. The TEG-PM was evaluated at two time points (prior to surgery and 12-48 hours after CPB).

Results:

Fifty-three children were studied; mean age was 6.6 (range: 0.07-16.7) years and 45% (n = 24) were female. Participants were distributed into two groups by ketorolac use, 41 within the ketorolac group and 12 in the no ketorolac group. All 41 participants who received ketorolac had platelet inhibition and 11 (91.7%) of 12 participants who did not receive ketorolac had normal platelet function after surgery ( P < .0001). There was no difference in patient characteristics or clinical data between the two groups.

Conclusions:

Ketorolac use in a cohort of children after congenital cardiac surgery was associated with platelet inhibition via the AA pathway when evaluated by TEG-PM.

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.