Deep Venous Thrombosis in Children With Diabetic Ketoacidosis and Femoral Central Venous Catheters

Abstract

ABSTRACT. Objective. To describe findings of deep venous thrombosis (DVT) in association with femoral central venous catheter (CVC) placement for intensive fluid management in children with diabetic ketoacidosis (DKA) secondary to type 1 diabetes.Design. Retrospective cohort study. Setting. Pediatric intensive care unit (PICU) of a children's referral medical center.Patients. DKA patients from 1998 to 2002 of children with DKA with and without CVC placement. DKA patients were also compared with all PICU patients with CVC. CVC DVT was defined as ipsilateral leg swelling with CVC placement, confirmed by radiographic study, and persisting after CVC removal.Measurements and Main Results. Of 113 DKA PICU patients, 6 (5.3%) required femoral CVC for initial management. Three of these DKA/CVC patients developed ipsilateral DVT within 48 hours of CVC placement. All 3 patients required long-term therapy with low molecular weight heparin for persistent leg swelling. DKA/CVC patients with DVT were younger (median age: 10.5 months) than DKA/CVC patients without DVT. The number of DKA/CVC patients with DVT (1.4%) was significantly greater than for all femoral non-DKA/CVC patients. DKA/CVC patients were also significantly more likely to have DVT than age-matched shock/CVC patients. They also had significantly higher glucose, corrected sodium concentrations, and lower pH and serum bicarbonate than did age-matched shock/CVC patients.Conclusions. Femoral CVC placement is infrequently needed in pediatric DKA patients but can be associated with DVT. Femoral CVCs should be avoided in DKA patients or removed as soon as possible. DVT prophylaxis should be considered if a CVC is required. C entral venous catheter (CVC) placement can be essential for providing fluids and medications in the treatment of the child with hypoperfusion and difficulty obtaining adequate peripheral access. CVCs, however, are associated with a variety of infectious and noninfectious complications. 1,2 Both percutaneous and chronic indwelling CVCs are a significant risk factor for deep venous thrombosis (DVT) in children. 1,2 Pediatric venous thromboembolism registries have reported that 28% to 50% of DVT episodes in children occurred in the presence of an acute or chronic CVC. 3,4 The reported incidence of DVT in pediatric intensive care unit (PICU) patients with a CVC ranges widely depending on whether clinical or radiographic evidence of DVT is evaluated. 1,[5][6][7][8] One prospective study of acute CVC placement in PICU patients found a 7.5% incidence of symptomatic DVT but an incidence of 18.3% based on radiographic evidence. 1 Previous experience has demonstrated increased incidence of DVT in children with chronic conditions such as malignancy or congenital heart disease or with acute infection, surgery, trauma, or hypovolemia. 9,10 Diabetes mellitus has not been described as a specific isolated risk factor for DVT in children, although a propensity for hypercoagulability has been noted in diabetic adults. 11 Despite growing experience regarding CVC-relat...

DKA and thrombosis

“…The corrected sodium level was 144 mmol/L with a calculated serum osmolarity of 331 mOsm/L. We agree that patients with DKA have hyperosmolarity because of hyperglycemia and hypernatremic dehydration, and we 1 and others 2,3 have suggested that the hyperosmolarity contributes to the prothrombotic tendency of children with DKA.…”

“…2 The mostly adult entity of hyperosmolar nonketotic coma has had various degrees of association with thrombosis, 2,3 as has extreme hypernatremia in breast-feeding neonates. 4 Recent evidence has also demonstrated that among children with DKA, there is a higher incidence of deep venous thrombosis with femoral central venous lines.…”

DKA and thrombosis

“…4 Recent evidence has also demonstrated that among children with DKA, there is a higher incidence of deep venous thrombosis with femoral central venous lines. 5,6 Serum glucose and sodium concentrations and hence effective plasma osmolarity were significantly higher in those patients with blood clots. 5 Although there is no direct evidence for its efficacy, our practice has been to use prophylactic anticoagulation in patients with DKA who are in a significant hyperosmolar state, as well as to eliminate the use of femoral catheters in patients with these risk factors.…”

“…5,6 Serum glucose and sodium concentrations and hence effective plasma osmolarity were significantly higher in those patients with blood clots. 5 Although there is no direct evidence for its efficacy, our practice has been to use prophylactic anticoagulation in patients with DKA who are in a significant hyperosmolar state, as well as to eliminate the use of femoral catheters in patients with these risk factors. There is significant controversy surrounding the dose of anticoagulant therapy, specifically whether the efficacy of dosages for prophylaxis of deep venous thrombosis outweighs the risks associated with full systemic anticoagulation.…”

Diabetic Ketoacidosis

“…In the medical literature there have been few reported cases CVC related VTE in DKA children without known risk factors. [208][209][210]. Thus, DKA and its treatment may promote a prothrombotic state and activation of vascular endothelium, predisposing to thrombosis.…”