Acute venous or arterial thrombosis

Is there clinical concern for an anatomic compressive syndrome or occlusive iliofemoral or IVC DVT?____________________________________Consider anatomic thrombotic obstruction:May-Thurner Syndrome-Acute occlusive iliofemoral vein/lower IVC thrombosis in left lower extremity

Paget-Schroetter Syndrome-Subclavian thrombosis with recent vigorous exercise of upper extremity (pitcher, drummer, etc.)

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 UFH or Enoxaparin_____________________________________________Start Enoxaparin:<3 month old 1.7mg/kg/dose BID3-12 months old 1.5mg/kg/dose BID1-5 years old 1.2mg/kg/dose BID6-18 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/doseGoal PTT 65-100 seconds (Consider only 24-72 hrs) and anti-FXa inhibition 0.35-0.7

Does patient meet inclusion and exclusion criteria for tPA?

Check baseline tPA labs:CBCPT/PTTFibrinogen activityPlasminogen activityD-dimer (quantitative)FVIII activityCMPCRP

Vanderbilt Pediatric Hematology Thrombolysis (tPA) Protocol

Inclusion Criteria for tPA-Symptoms present < 14 days-Thrombus site and extent confirmed by objective imaging-No more than 48 hours of UFHor LMWH for thrombus (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

KeyUFH: Unfractionated HeparinLMWH: Low molecular weight HeparinCNS: Central Nervous SystemtPA: Tissue Plasminogen Activator (usually alteplase)Gtt: dripHIT: Heparin induced thrombocytopenia

No

Yes

Systemic tPA1) Begin systemic tPA: - 0.06mg/kg/hr if <2 months of age - 0.03mg/kg/hr if >2 months of age2) Perform cranial U/S if <1 month old within 7days3) Concurrent UFH gtt at 10 Units/kg/hr -Do not adjust PTT to therapeutic goal4) tPA labs q8hrs5) Maintain fibrinogen and plt count >1006) tPA x 24 hours and re-image with U/S

Catheter-directed tPA1) Contact Interventional Radiology for catheter-directed tPA2) Start therapeutic UFH gtt 3) Make NPO for procedure4) Start mIVF5) Lab goals: Platelet >100k Fibrinogen >100mg/dL6) CTA/V of affected area prior to catheter-directed tPA7) Once catheter tPA done: a) Goal PTT 65-100 seconds x 48hrs b) Check tPA labs q8h x 48 hrs c) Convert to Enoxaparin after 48hrs

Yes

No

Robert F. Sidonio, Jr. MD, MSc.

tPA labsCBCPT/PTTFibrinogen activityD-dimer (quantitative)BMP -CMP if LFTS abnormal at baseline

No clot lysisDouble tPA doseRepeat U/S in 24hrs

>0-50% clot lysisIncrease tPA by 50%Repeat U/S in 24hrs

>50-95% clot lysisCont. same dose tPARepeat U/S in 24hrs

>95% clot lysisStop tPA-Therapeutic UFH x 48 hrs- tPA labs x 48hrs-Switch to Enoxaparin

0-50% clot lysisEither the following:-Continue same tPA dose and repeat U/S in 24hrs

-Stop tPA __________________________________________Once tPA done:Therapeutic UFH x 48 hrs, tPA labs x 48hrsSwitch to Enoxaparin

>50-100% clot lysisEither the following:-Continue same tPA dose and repeat U/S in 24hrs

-Stop tPA ________________________________________Once tPA done:Therapeutic UFH x 48 hrs, tPA labs x 48hrsSwitch to Enoxaparin

Indications for thrombolysisStrong 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

4/1/12