1. Acute venous or arterial thrombosis Acute venous or arterial thrombosis Is there an indication for thrombolysis? Baseline labs: CBC, PT, PTT, fibrinogen activity, FVIII activity, D-dimer (quantitative) and CRP -Defer hypercoaguability workup until outpatient -Start Enoxaparin or UFH ____________________________________________ _ Start Enoxaparin: <3 month old 1.7mg/kg/dose BID 3-12 months old 1.5mg/kg/dose BID 1-5 years old 1.2mg/kg/dose BID 6-18 years of age 1mg/kg/dose BID -Notify Kathy Jernigan for teaching (pager 831-6629) Goal anti-FXa 0.5-1, 4-5 hours after second dose ____________________________________________ UFH (clinically unstable, expected surgery or post- cardiac surgery) : Load: 75 units/kg over 10 minutes (max 5000 units) Maintenance: < 1 year of age: 28 units/kg/hr ≥ 1 year of age: 20 units/kg/dose Goal PTT 65-100 seconds (Consider only 24-72 hrs) and anti-FXa 0.35-0.7 Baseline labs: CBC, PT, PTT, fibrinogen activity, FVIII activity, D-dimer (quantitative) and CRP -Defer hypercoaguability workup until outpatient -Start Enoxaparin or UFH ____________________________________________ _ Start Enoxaparin: <3 month old 1.7mg/kg/dose BID 3-12 months old 1.5mg/kg/dose BID 1-5 years old 1.2mg/kg/dose BID 6-18 years of age 1mg/kg/dose BID -Notify Kathy Jernigan for teaching (pager 831-6629) Goal anti-FXa 0.5-1, 4-5 hours after second dose ____________________________________________ UFH (clinically unstable, expected surgery or post- cardiac surgery) : Load: 75 units/kg over 10 minutes (max 5000 units) Maintenance: < 1 year of age: 28 units/kg/hr ≥ 1 year of age: 20 units/kg/dose Goal PTT 65-100 seconds (Consider only 24-72 hrs) and anti-FXa 0.35-0.7 Does patient meet inclusion and exclusion criteria for tPA? See thrombolysis protocol Vanderbilt Pediatric Hematology Thrombosis Protocol Inclusion Criteria for tPA Symptoms present < 14 days Thrombus site and extent confirmed by objective imaging No more than 48 hours of UFH or LMWH for this thrombus For systemic tPA only Platelet count > 100,000/  l Fibrinogen > 100 mg/dl No thrombus in previous site Exclusion criteria for tPA Active bleeding Active seizures < 48 hours Invasive procedure < 3 days (chest tube, lumbar puncture, liver biopsy etc) Major surgery < 10 days CNS bleeding or surgery < 14 days History of HIT Allergic reaction to UFH, LMWH or alteplase Renal or liver failure Uncontrolled Hypertension Yes No Yes Robert F. Sidonio, Jr. MD, MSc. Indications for thrombolysis Strong Indications Life, limb or organ-threatening thrombosis Arterial or venous thrombosis causing ischemia Superior Vena Cava Syndrome Massive PE with cardio instability Bilateral renal vein thrombosis Cerebral Sinovenous thrombosis with neurologic decline Large atrial thrombi (congenital heart disease) Intermediate Indications Acute iliofemoral or IVC thrombosis May-Thurner Syndrome Paget-Schroetter Syndrome Obtain pediatric hematology consult 4/11/12 Non-occlusive DVT Cerebral sinovenous thrombosis Occlusive SVC, IVC or iiofemoral DVT Length of therapy? Clinic follow-up Every 6 weeks for labs, physical exam and possible imaging Repeat CT/MRI q3 months until resolution or total 9 months for brain thromboses Repeat Ultrasound q6 weeks until resolution or total 9 months for peripheral thromboses Clinic thrombosis labs (every visit) CBC, FVIII activity, D-dimer (quantitative), CRP, BMP and PT/INR (if on Coumadin) Defer hypercoaguable evaluation until off Coumadin >2 weeks Hypercoaguable evaluation only to be sent as outpatient PE: Send HYC panel + homocysteine + lipoprotein(a) DVT: Send HYC panel + homocysteine 6 weeks Stop anticoagulation if ALL: Complete resolution on U/S Transient risk factor resolved Normalized 2 of 3 inflammatory markers (CRP, D- dimer, FVIII) 6 weeks Stop anticoagulation if ALL: Complete resolution on U/S Transient risk factor resolved Normalized 2 of 3 inflammatory markers (CRP, D- dimer, FVIII) Transient DVT risk factors Line placed during acute illness Osteomyelitis Cellulitis Myositis Pneumonia Sepsis Exogenous estrogen (OCPs) 3 months Stop anticoagulation if ALL: Complete resolution on CT/MR Transient risk factor resolved Normalized 2 of 3 inflammatory markers (CRP, D-dimer, FVIII) 3 months Stop anticoagulation if ALL: Complete resolution on CT/MR Transient risk factor resolved Normalized 2 of 3 inflammatory markers (CRP, D-dimer, FVIII) 6 months Stop anticoagulation if ALL: Complete resolution on CT/MR Transient risk factor resolved Normalized 2 of 3 inflammatory markers (CRP, D-dimer, FVIII) 6 months Stop anticoagulation if ALL: Complete resolution on CT/MR Transient risk factor resolved Normalized 2 of 3 inflammatory markers (CRP, D-dimer, FVIII) Pulmonary embolus 6 months Stop anticoagulation if ALL: Complete resolution on CT/MR Transient risk factor resolved Normalized 2 of 3 inflammatory markers (CRP, D-dimer, FVIII) 6 months Stop anticoagulation if ALL: Complete resolution on CT/MR Transient risk factor resolved Normalized 2 of 3 inflammatory markers (CRP, D-dimer, FVIII) Other considerations Consider Coumadin as outpatient with education and enrollment in Coumadin Clinic. Avoid insuflon catheters. Candidates for anticoagulation thromboprophylaxis Elevated lipoprotein (a) Protein S/C deficiency Antithrombin deficiency Antiphospholipid antibody syndrome DVT or PE x 2 without inherited thrombophilia IBD/Lupus patient hospitalized for acute illness without acute bleeding Cancer and history of thrombus Inherited thrombophilia patients the following scenarios: Acute illness requiring hospitalization Bone fracture that does not allow full ambulation Spinal Cord trauma without bleeding Any surgery that does not allow full ambulation within 12 hours Key UFH: Unfractionated Heparin LMWH: Low molecular weight Heparin CNS: Central Nervous System tPA: Tissue Plasminogen Activator (usually alteplase) gtt: drip HIT: Heparin induced thrombocytopenia PT: Prothrombin time INR: International normalized ratio HYC panel: Activated protein C resistance ratio (with reflex FVL PCR), protein C/S activity, antithrombin activity, PT gene miutation + LUP panel. LUP panel: Thrombin time, dRVVT ratio (with mix if positive), STAClot LA, Anticardiolipin antibodies and Beta- glycoprotein antibodies Consider long term anticoagulation Single Ventricle Physiology Indefinite Coumadin with goal INR 2-3 Lupus If thrombus + antiphospholipid antibody consider indefinite anticoagulation Cancer ALL – treatment until resolution of clot (3m), prophylaxis until maintenance phase Solid tumor - treatment until resolution of clot (3m), prophylaxis until remission