Maile Parker, MSIV University of Washington School of Medicine Sept. 27, 2012 Venous Thromboembolism Prophylaxis in Pediatric Patients With Central Venous.

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Presentation transcript:

Maile Parker, MSIV University of Washington School of Medicine Sept. 27, 2012 Venous Thromboembolism Prophylaxis in Pediatric Patients With Central Venous Catheters

Goals  Discuss incidence and risk factors for CVC related VTE  Determine whether there is evidence for pharmacologic VTE prophylaxis in pediatric population with CVCs

Definitions  DVT= thrombosis of internal jugular vein or deep veins of extremities  VTE= DVT or pulmonary embolism  CVC= intravenous catheter inserted through a large vein and ending in the vena cava or right atrium  Thrombosis/VTE vs catheter occlusion: Thrombosis= clot in vessel, occlusion=clot only in catheter

Venous thromboembolism  Virchow’s triad

Risk factors  Malignancy  Older age  OCP/pregnancy  Central venous access  Immobility >72 h  Long bone fractures/surgery  Spinal cord injury  Congenital prothrombotic risk factors

 Contrast venography (gold standard)  Venous duplex

Pediatric population  Incidence of VTE in children poorly characterized  Lack of consensus/guidelines regarding risk stratification and prophylaxis in children

Physiology  Lower risk of VTE in children

Epidemiology  Incidence: /10,000 children/year, 5/10,000 hospital admissions  Mortality rate ~ 2%  2/3 of VTEs diagnosed in children are associated with central venous catheters (CVC)

 Incidence of VTE in children with CVC is 25-40%  Multi lumen> single lumen  Femoral> Internal Jugular> Subclavian

Is VTE prophylaxis indicated in children with central lines?

2 RCTs regarding chemoprophylaxis of CVC related thrombosis in kids: Massicotte P, Julian JA, Gent M; et al. PROTEKT Study Group, An open-label randomized controlled trial of low molecular weight heparin for the prevention of central venous line-related thrombotic complications in children: the PROTEKT trial, Thromb Res

PROphylaxis of ThromboEmbolism in Kids Trial (PROTEKT)  Population: Patients 36 wk GA-18 y with first CVC  Intervention/comparison: Randomized to systemic doses of LMWH or standard care  Outcomes:  Clinically significant VTE, or DVT on exit venogram (day 30 or day of line removal)  Major bleeding event

Schroeder AR, Axelrod DM et al; A continuous heparin infusion does not prevent catheter- related thrombosis in infants after cardiac surgery, Pediatric Critical Care Med

 Population: 90 infants <1 y/o undergoing cardiac surgery  Intervention/comparison: Continuous 10 unit/kg/h heparin infusion vs placebo  Outcomes:  catheter thrombosis  catheter malfunction  bleeding

Conclusions  Based on current evidence, systemic administration of unfractionated heparin or LMWH does not decrease VTE risk in children with CVC

References Sandoval, John A, Sheehan, Michael P, Stonerock, Charles E, Shafique, Shoaib, Rescorla, Frederick J, Dalsing, Michael C. Incidence, risk factors, and treatment patterns for deep venous thrombosis in hospitalized children: An increasing population at risk. Journal of Vascular Surgery, Volume 47, Issue 4, April 2008, Pages 837–843 Brian W. Gray, Raquel Gonzalez, Kavita S. Warrier, Lauren A. Stephens, Robert A. Drongowski, Steven W. Pipe, George B. Mychaliska, Characterization of central venous catheter–associated deep venous thrombosis in infants, Journal of Pediatric Surgery, Volume 47, Issue 6, June 2012, Pages Paul Monagle, MBBS, MD, FCCP; Anthony K. C. Chan, MBBS; Neil A. Goldenberg, MD, PhD; Rebecca N. Ichord, MD; Janna M. Journeycake, MD, MSCS; Ulrike Nowak-Göttl, MD; Sara K. Vesely, PhD. Antithrombotic Therapy in Neonates and Children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST, 2012, Volume 141, Issue 2, No. 2 suppl Massicotte P, Julian JA, Gent M; et al. PROTEKT Study Group, An open-label randomized controlled trial of low molecular weight heparin for the prevention of central venous line-related thrombotic complications in children: the PROTEKT trial, Thromb Res Schroeder AR, Axelrod DM, Silverman NH, Rubesova E, Merkel E, Roth SJ; A continuous heparin infusion does not prevent catheter-related thrombosis in infants after cardiac surgery, Pediatr Crit Care Med