Incidence and Acute Complications of Asymptomatic Central Venous Catheter-Related Deep Venous Thrombosis in Critically Ill Children
ABSTRACT OBJECTIVE: To determined the current incidence and acute complications of asymptomatic central venous catheter (CVC)-related deep venous thrombosis (DVT) in critically ill children. STUDY DESIGN: We performed a prospective cohort study in 3 pediatric intensive care units. A total of 101 children with newly inserted untunneled CVC were included. CVC-related DVT was diagnosed using compression ultrasonography with color Doppler. RESULTS: Asymptomatic CVC-related DVT was diagnosed in 16 (15.8%) children, which equated to 24.7 cases per 1000 CVC-days. Age was independently associated with DVT. Compared with children aged <1 year, children aged >13 years had significantly higher odds of DVT (aOR, 14.1, 95% CI, 1.9-105.8; P = .01). Other patient demographics, interventions (including anticoagulant use), and CVC characteristics did not differ between children with and without DVT. Mortality-adjusted duration of mechanical ventilation, a surrogate for pulmonary embolism, was statistically similar in the 2 groups (22 ± 9 days in children with DVT vs 23 ± 7 days in children without DVT; P = .34). Mortality-adjusted intensive care unit and hospital lengths of stay also were similar in the 2 groups. CONCLUSION: Asymptomatic CVC-related DVT is common in critically ill children. However, the acute complications do not seem to differ between children with and without DVT. Larger studies are needed to confirm these results. Future studies should also investigate the chronic complications of asymptomatic CVC-related DVT.
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ABSTRACT: Intrapulmonary arteriovenous anastomoses (IPAVs) are large-diameter pathways that directly connect the arterial and venous networks, bypassing the pulmonary capillaries. Ubiquitously present in healthy humans, these pathways are recruited in experimental conditions by exercise, hypoxia, and catecholamines and have been previously shown to be closed by hyperoxia. Whether they play a role in pulmonary pathophysiology is unknown. Here, we describe IPAV recruitment associated with hypoxemia and right-to-left shunt in a patient with status asthmaticus, treated with agonists of the B2-adrenergic pathway. Our observation of IPAVs in a pediatric patient, mechanically ventilated with 100% O2, suggests that these pathways are recruited in clinically important circumstances and challenges the notion that IPAVs are always closed by alveolar hyperoxia.PEDIATRICS 03/2014; 133(4). DOI:10.1542/peds.2013-1171 · 5.30 Impact Factor
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ABSTRACT: Objectives In preparation for a pediatric randomized controlled trial on thromboprophylaxis, we determined the frequency of catheter-related thrombosis in children. We also systematically reviewed the pediatric trials on thromboprophylaxis to evaluate its efficacy and to identify possible pitfalls in the conduct of these trialsPatients/methodsWe searched MEDLINE, EMBASE, Web of Science and Cochrane Central Register for Controlled Trials for articles published until December 2013. We included cohort studies and trials on patients 0-18 years old with central venous catheter actively surveilled for thrombosis with radiologic imaging. We estimated the pooled frequency of thrombosis and the pooled risk ratio (RR) with thromboprophylaxis using random effects modelResultsOf 2,651 articles identified, we analyzed 37 articles with 3,128 patients. The pooled frequency of thrombosis was 0.20 (95% confidence interval [CI]: 0.16-0.24). Of 10 trials, we did not find evidence that heparin-bonded catheter (RR: 0.34; 95% CI: 0.01-7.68), unfractionated heparin (RR: 0.93; 95% CI: 0.57-1.51), low molecular weight heparin (RR: 1.13; 95% CI: 0.51-2.50), warfarin (RR: 0.85; 95% CI: 0.34-2.17), antithrombin concentrate (RR: 0.76; 95% CI: 0.38-1.55) and nitroglycerin (RR: 1.53; 95% CI: 0.57-4.10) reduced the risk for thrombosis. Most of the trials were either not powered for thrombosis or powered to detect large, likely unachievable, reductions in thrombosis. Missing data on thrombosis also limited these trialsConclusions Catheter-related thrombosis is common in children. An adequately powered multicenter trial that can detect a modest, clinically significant, reduction in thrombosis is critically needed. Missing outcome data should be minimized in this trialThis article is protected by copyright. All rights reserved.Journal of Thrombosis and Haemostasis 05/2014; 13(1). DOI:10.1111/jth.12598 · 5.55 Impact Factor
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ABSTRACT: Background The ability to predict the development of venous thromboembolism is highly desirable.Objective We aim to determine the association between hyperglycemia and venous thromboembolism in non-diabetic critically ill children.Patients/Methods We conducted a retrospective cohort study that included children in the pediatric intensive care unit on vasopressor or on mechanical ventilator and without history of diabetes mellitus or prior diagnosis of thrombosis. Based on maximum blood glucose >150 mg/dl while admitted to the unit, children were categorized as hyperglycemic or non-hyperglycemic. Primary outcome was development of venous thromboembolism while admitted to the unit. We determined the association between hyperglycemia and venous thromboembolism using logistic regression models adjusting for selected subject characteristics.ResultsOf the 789 subjects analyzed, 34 subjects developed venous thromboembolism (incidence: 4.3%; 95% confidence interval: 3.0%-6.0%). Venous thromboembolism was more likely to develop in hyperglycemic subjects compared with non-hyperglycemic subjects. A total of 31 subjects (6.2%; 95% confidence interval: 4.2%-8.7%) developed venous thromboembolism after becoming hyperglycemic compared with 3 non-hyperglycemic subjects with venous thromboembolism (1.0%, 95% confidence interval: 0.2%-3.0%). When adjusted for age, diagnosis, presence of central venous catheter, prophylactic antithrombotic use and severity of illness, the odds ratio of venous thromboembolism with hyperglycemia was 4.1 (95% confidence interval: 1.2-14.1). For every 10 mg/dl increase in maximum blood glucose, adjusted odds ratio of venous thromboembolism was 1.04 (95% confidence interval: 1.01-1.06).Conclusion Hyperglycemia is associated with venous thromboembolism in critically ill non-diabetic children. Maximum blood glucose is a potential predictor of venous thromboembolism in this population.This article is protected by copyright. All rights reserved.Journal of Thrombosis and Haemostasis 04/2014; 12(6). DOI:10.1111/jth.12583 · 5.55 Impact Factor