How I treat pediatric venous thromboembolism

Abstract

The incidence of pediatric venous thromboembolism (VTE) has been increasing significantly over the past decade in part as a result of increased recognition of this serious disorder but more so because of the increased use of central venous catheters and other technological advancements involved in the care of ill children. Management of pediatric VTE is a complex undertaking, considering that the vast majority of children who develop this complication have serious underlying medical disorders. Although the incidence is rising, in comparison with adults, this remains a relatively rare disorder, and as such, large-scale clinical trials have not been completed, rendering management decisions to be based on extrapolation from adult data and the experience of the treating physician. Clearly, both are fraught with problems. Thus, day-to-day management remains more art than science until such time that the results from clinical trials (many of which are under way) become available. This edition of “How I Treat” describes the author’s experience in managing 3 common scenarios that one may encounter in pediatric thrombosis and suggests a logical approach to such situations. Furthermore, the author provides 3 algorithms to help guide management decisions.

Recurrent intestinal ischemia following surgery for gastric and duodenal perforations: a case report

“…After the development of NEC, we initiated heparin-based anticoagulation therapy because we predicted extensive intestinal ischemia. According to the algorithm for anticoagulation selection for pediatric venous thromboembolism by age, heparin is selected for patients less than 1 year of age [8]. We speculate that the administration of heparin at 0.2 U/kg/h may have resulted in the shrinkage of the thrombus and subsequent improvement in the blood flow in the intestines.…”

Updated recommendations for the treatment of venous thromboembolism

“…The developmental stage of the hemostatic system in children, physiologically lower levels of coagulant and anticoagulant proteins, and other confounding factors, such as concomitant use of drug, infection, or inflammation, should be addressed [ 68 - 70 ]. Generally, the tests for thrombophilia do not change decisions about the initiation and duration of acute management, except for specific patients with purpura fulminans complicating severe protein C or S deficiency or cases with VKA-induced skin necrosis [ 71 - 73 ].…”

“…It is suggested to use anticoagulation for ≤3 months in children with provoked DVT or PE and for 6 to 12 months in unprovoked DVT or PE [ 77 ]. Patients with recurrent thrombosis and antiphospholipid antibody syndrome often require indefinite anticoagulation [ 72 ]. Therapeutic UFH in children is titrated to achieve an activated partial thromboplastin time range (aPTT) of 1.5 to 2.5 times the upper limit of normal [ 77 ].…”

Catheter‐directed thrombolysis for submassive pulmonary embolism in children: A case series

“…Given the equipoise on the role of thrombolytic therapy in the management of submassive PE in adults, it is not surprising that the optimum management of this condition in children is unknown. This deficiency was highlighted in recent reviews and consensus guidelines, including a communication from the pediatric and neonatal subcommittee of the International Society on Thrombosis and Haemostasis (ISTH) …”

“…This deficiency was highlighted in recent reviews and consensus guidelines, including a communication from the pediatric and neonatal subcommittee of the International Society on Thrombosis and Haemostasis (ISTH). [14][15][16] At Nationwide Children's Hospital (NCH), a quaternary care, freestanding Children's Hospital in the Midwest, management of PE is individualized based on clinical, radiological, and laboratory parameters.…”