acute venous or arterial thrombosis acute venous or arterial thrombosis is there clinical concern...

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