Article

Current and future management of pediatric venous thromboembolism

Division of Hem/Onc/BMT, Nationwide Children's Hospital, Columbus, Ohio, USA.
American Journal of Hematology (Impact Factor: 3.48). 05/2012; 87 Suppl 1(S1):S68-74. DOI: 10.1002/ajh.23131
Source: PubMed

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.

0 Followers
 · 
110 Views
  • Source
    • "Recent reports from Canada (24 per 10,000 NICU admissions[16] and the U.S. (58 cases per 10,000 admissions ) between 2001 and 2007 [2] indicate a 10-fold increase in pediatric VTE compared to the first prospective registry report of an annual incidence of 0.07 per 10,000 children or 5.3 per 10,000 hospital admissions [10], with the report from the US showing that the neonatal subpopulation experienced the highest increase (100%; from 25 to 50 cases per 10,000 admissions) in VTE incidence among the hospitalized population overall [2]. The dramatic increase in the incidence of pediatric and neonatal VTE has been attributed to a number of factors including an increased awareness and recognition of VTE, recent improvements in the care of children with underlying medical conditions associated with VTE that keep these children alive long enough to develop VTE and invasive medical interventions that may disrupt the vascular and/or hemostatic systems and result in the development of VTE [17]. In addition, a disadvantageous catheter-to-vessel-diameter ratio puts neonates at a higher HA-VTE risk compared to older children and adults. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Objective: To determine hospital-associated venous thromboembolism (HA-VTE) risk factors in critically ill neonates. Methods: We conducted a case-control study in the neonatal intensive care unit (NICU) of All Children's Hospital Johns Hopkins Medicine (St. Petersburg, FL), from January 1, 2006 - April 10, 2013. We identified HA-VTE cases using electronic health record. Four NICU controls were randomly selected for each HA-VTE case. Associations between putative risk factors and HA-VTE were estimated using odds ratios (ORs) and ninety-five percent confidence intervals (95%CIs) from univariate and multivariate regression analyses. Results: Twenty-three HA-VTE cases and 92 controls were included. The annual HA-VTE incidence was approximately 1.4 HA-VTE cases per 1,000 NICU admissions. In univariate analyses, mechanical ventilation (OR = 7.27, 95%CI = 2.02-26.17, P = 0.002), central venous catheter (CVC; OR = 52.95, 95%CI = 6.80-412.71, P < 0.001), infection (OR = 7.24, 95%CI = 2.66-19.72, P < 0.001), major surgery (OR = 5.60, 95%CI = 1.82-17.22, P = 0.003) and length of stay >= 15 days (OR = 6.67, 95%CI = 1.85-23.99, P = 0.004) were associated with HA-VTE. Only CVC (OR = 29.04, 95%CI = 3.18-265.26, P = 0.003) remained an independent risk factor in the multivariate analysis. Based on this result, the estimated risk of HA-VTE in NICU patients with a CVC was 0.9%. Conclusion: This study identifies CVC as an independent risk factor for HA-VTE in critically ill neonates. However, the level of risk associated with CVC is below the conventional threshold for primary anticoagulation thromboprophylaxis. Larger studies are needed to substantiate these findings and identify novel putative risk factors to further distinguish NICU patients at highest HA-VTE risk.
    Thrombosis Research 06/2014; 134(2). DOI:10.1016/j.thromres.2014.05.036 · 2.43 Impact Factor
  • Source
    • "Treatment of esophageal atresia (EA), a rare congenital anomaly, frequently requires utilization of interventions that may expose patients to prothrombotic risks. [4] [5] As early as the 1950s, Dr. Robert Gross proposed a classification scheme based on anatomical variants of esophageal atresia with and without a tracheoesophageal fistula [6]. A subgroup of patients with EA have long gap esophageal atresia (LGEA), which is often defined by a distance between the upper and a lower atretic esophageal segment of greater than three vertebral bodies [7]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: To determine the incidence of catheter-associated venous thromboembolic events (VTE) in long gap esophageal atresia (LGEA) patients treated at Boston Children's Hospital (BCH) and to identify possible risk factors associated with their development. We performed a retrospective analysis of LGEA patients from 2005 to 2012. Symptomatic VTEs with radiographic confirmation were defined as events. Potential risk factors were assessed by univariate analysis and multivariate logistic regression. Covariates included age, weight, initial gap length, cumulative days of pharmacologic paralysis and paralytic episodes, number and type of central venous catheters (CVCs), and number of operations. Forty-four LGEA patients were identified. The incidence of CVC associated VTE was 34%. Univariate analysis identified age at Foker 1 (P=.03), paralysis duration (P=.01), episodes of paralysis (P=.001), cumulative number of CVC (P=.007) and length of stay (P=.03) as significant. Multivariate logistic regression identified the number of paralytic episodes as the only significant independent risk factor for VTE (P<.0001). The incidence of symptomatic VTE was 34%, significantly higher than the VTE incidence of 4.5% reported for our other hospitalized children. These data have led to multidisciplinary discussions regarding thromboprophylaxis and development of a consensus-driven protocol. Since the initiation of this protocol, no VTEs have been identified.
    Journal of Pediatric Surgery 02/2014; 49(2):370-3. DOI:10.1016/j.jpedsurg.2013.09.003 · 1.31 Impact Factor
  • Source
    • "Recent reports from Canada (24 per 10,000 NICU admissions[16] and the U.S. (58 cases per 10,000 admissions ) between 2001 and 2007 [2] indicate a 10-fold increase in pediatric VTE compared to the first prospective registry report of an annual incidence of 0.07 per 10,000 children or 5.3 per 10,000 hospital admissions [10], with the report from the US showing that the neonatal subpopulation experienced the highest increase (100%; from 25 to 50 cases per 10,000 admissions) in VTE incidence among the hospitalized population overall [2]. The dramatic increase in the incidence of pediatric and neonatal VTE has been attributed to a number of factors including an increased awareness and recognition of VTE, recent improvements in the care of children with underlying medical conditions associated with VTE that keep these children alive long enough to develop VTE and invasive medical interventions that may disrupt the vascular and/or hemostatic systems and result in the development of VTE [17]. In addition, a disadvantageous catheter-to-vessel-diameter ratio puts neonates at a higher HA-VTE risk compared to older children and adults. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Objective To determine hospital-associated venous thromboembolism (HA-VTE) risk factors in critically ill neonates. Methods We conducted a case-control study in the neonatal intensive care unit (NICU) of All Children’s Hospital Johns Hopkins Medicine (St. Petersburg, FL), from January 1, 2006 - April 10, 2013. We identified HA-VTE cases using electronic health record. Four NICU controls were randomly selected for each HA-VTE case. Associations between putative risk factors and HA-VTE were estimated using odds ratios (ORs) and ninety-five percent confidence intervals (95%CIs) from univariate and multivariate regression analyses. Results Twenty-three HA-VTE cases and 92 controls were included. The annual HA-VTE incidence was approximately 1.4 HA-VTE cases per 1,000 NICU admissions. In univariate analyses, mechanical ventilation (OR = 7.27, 95%CI = 2.02-26.17, P = 0.002), central venous catheter (CVC; OR = 52.95, 95%CI = 6.80-412.71, P < 0.001), infection (OR = 7.24, 95%CI = 2.66-19.72, P < 0.001), major surgery (OR = 5.60, 95%CI = 1.82-17.22, P = 0.003) and length of stay ≥ 15 days (OR = 6.67, 95%CI = 1.85-23.99, P = 0.004) were associated with HA-VTE. Only CVC (OR = 29.04, 95%CI = 3.18-265.26, P = 0.003) remained an independent risk factor in the multivariate analysis. Based on this result, the estimated risk of HA-VTE in NICU patients with a CVC was 0.9%. Conclusion This study identifies CVC as an independent risk factor for HA-VTE in critically ill neonates. However, the level of risk associated with CVC is below the conventional threshold for primary anticoagulation thromboprophylaxis. Larger studies are needed to substantiate these findings and identify novel putative risk factors to further distinguish NICU patients at highest HA-VTE risk.
    Thrombosis Research 01/2014; · 2.43 Impact Factor
Show more

Preview

Download
3 Downloads