The goals were to determine whether there has been an increase in the rate of venous thromboembolism (VTE) in pediatric tertiary care hospitals and to evaluate the use of anticoagulants in the ...treatment of hospitalized pediatric patients with VTE.
A retrospective cohort study of patients <18 years of age who were discharged from 35 to 40 children's hospitals (depending on the year) across the United States in 2001-2007 was performed. By using the Pediatric Health Information System administrative database, cases were assessed for discharge diagnosis codes for VTE; the use of anticoagulants was assessed by using patient-specific pharmacy files.
During the 7-year study period, in which 11 337 hospitalized patients were diagnosed with VTE, the annual rate of VTE increased by 70%, from 34 to 58 cases per 10,000 hospital admissions (P < .001). This increase was observed in neonates, infants, children, and adolescents. The majority (63%) of children with VTE had > or =1 coexisting chronic complex medical condition. Pediatric malignancy was the medical comorbid condition associated most strongly with recurrent VTE (P < .001). The proportion of children with VTE who were treated with enoxaparin increased from 29% to 49% during this time period (P < .001); the use of warfarin decreased slightly from 11.4% to 9.6% (P= .02). Increasing age was associated with increased likelihood of patients with VTE being treated with either enoxaparin or warfarin.
This multicenter study demonstrates a dramatic increase in the diagnosis of VTE at children's hospitals from 2001 to 2007.
Children with myocarditis have multiple risk factors for thrombotic events, yet the role of antithrombotic therapy is unclear in this population. We hypothesised that thrombotic events in critically ...ill children with myocarditis are common and that children with myocarditis are at higher risk for thrombotic events than children with non-inflammatory dilated cardiomyopathy.
This is a retrospective chart review of all children presenting to a single centre cardiac intensive care unit with myocarditis from 1995 to 2008. A comparison group of children with dilated cardiomyopathy was also examined. Antithrombotic regimens were recorded. The primary outcome of thrombotic events included intracardiac clots and any thromboembolic events.
Out of 45 cases with myocarditis, 40% were biopsy-proven, 24% viral polymerase chain reaction-supported, and 36% diagnosed based on high clinical suspicion. There were two (4.4%) thrombotic events in the myocarditis group and three (6.7%) in the dilated cardiomyopathy group (p = 1.0). Neither the use of any antiplatelet or anticoagulation therapy, use of intravenous immune globulin, presence of any arrhythmia, nor need for mechanical circulatory support were predictive of thrombotic events in the myocarditis, dilated cardiomyopathy, or combined groups.
Thrombotic events in critically ill children with myocarditis and dilated cardiomyopathy occurred in 6% of the combined cohort. There was no difference in thrombotic events between inflammatory and non-inflammatory cardiomyopathy groups, suggesting that the decision to use antithrombotic prophylaxis should be based on factors other than the underlying aetiology of a child's acute decompensated heart failure.
Central venous catheters (CVC) are the most significant risk factor for pediatric venous thromboembolism (VTE). After an index CVC-associated VTE (CVC-VTE), the role of secondary prophylaxis for ...subsequent CVC placement is uncertain. Aims of this single-center retrospective study were to evaluate the efficacy of secondary prophylaxis for patients with a prior CVC-VTE and identify risk factors associated with recurrent VTE in patients less than 19 years with an index CVC-VTE between 2003 and 2013. Data collection included clinical and demographic factors, subsequent CVC placement, secondary prophylaxis strategy, recurrent VTE, and bleeding. Risk factors for recurrence and effectiveness of secondary prophylaxis were evaluated using survival and binomial models. Among 373 patients with an index CVC-VTE, 239 (64.1%) had subsequent CVC placement; 17.4% (65/373) of patients had recurrent VTE, of which 90.8% (59/65) were CVC-associated. On multivariable survival analysis, each additional CVC (hazards ratio HR 12.00; 95% confidence interval CI 2.78-51.91), congenital heart disease (HR 3.70; 95% CI 1.97-6.95), and total parenteral nutrition dependence (HR 4.02; 95% CI 2.23-7.28) were associated with an increased hazard of recurrence. Full dose anticoagulation for secondary prophylaxis was associated with decreased odds of recurrent CVC-VTE (odds ratio OR 0.35; 95% CI 0.19-0.65) but not prophylactic dosing (OR 0.61; 95% CI 0.28-1.30). Only 1.3% of CVCs experienced major bleeding with prophylactic or full-dose anticoagulation. In summary, children with CVC-VTE are at increased risk for recurrent VTE. Secondary prophylaxis with full-dose anticoagulation was associated with a 65% reduction in odds of thrombotic events.
•Children with a history of CVC-associated thrombosis are at increased risk for recurrent VTE.•With subsequent CVC placement, secondary prophylaxis with full-dose anticoagulation was associated with a 65% reduction in thromboembolism.
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Introduction
Intracranial haemorrhage (ICH) in patients with haemophilia has an estimated mortality rate of 20%. Advances in haemophilia care have significantly reduced many bleeding complications ...but it is unclear if these advances have impacted mortality from ICH.
Aim
To determine the in‐hospital mortality from intracranial ICH in paediatric patients with haemophilia.
Methods
This retrospective multicentre cohort study utilized the Pediatric Health Information System administrative database with data from 43 paediatric tertiary care hospitals in the United States from January 1, 2002–December 31, 2011. Subjects included were male < 21 years of age with an ICD‐9‐CM code for haemophilia A or B. ICH events were identified using ICD‐9‐CM codes.
Results
There were 8325 admissions for 3133 male subjects with haemophilia. About 271 (3.3%) admissions had an ICH event in 236 (7.5%) individual subjects. The proportion of ICH events was stable over time (P = 0.13). The median age of ICH was 2 years (interquartile range 0.6–7.3). In 28.4% (77/271) of the ICH events the subject had an inhibitor. Twenty‐one deaths occurred in the entire cohort (0.7%). Six (28.6%) of these deaths were in patients with an ICH for an ICH mortality rate of 2.5% (6/236).
Conclusions
Mortality from ICH in paediatric patients has significantly improved from prior estimates of 20% to the current estimate of 2.5%. Unfortunately the rate of ICH events remains constant and further efforts are needed to identify alternative strategies of prevention.
Venous thromboembolism (VTE) incidence in children has sharply increased with the majority of cases secondary to central venous catheters (CVCs). Among CVCs, the number of peripherally inserted ...central catheters (PICCs) placed has risen significantly. In this multicenter, prospective, observational cohort study, we enrolled patients aged 6 months to 18 years with newly placed PICCs or tunneled lines (TLs). We evaluated the incidence of VTE, central line–associated bloodstream infections (CLABSIs), and catheter malfunctions in PICCs and TLs, and risk factors of CVC-related VTE. A total of 1967 CVCs were included in the analysis. The incidence of CVC-related VTE was 5.9% ± 0.63%. The majority of the cases, 80%, were in subjects with PICCs, which had a significantly higher risk of catheter-related VTE than subjects with TLs (hazard ratio HR = 8.5; 95% confidence interval CI, 3.1-23; P < .001). PICCs were significantly more likely to have a CLABSI (HR = 1.6; 95% CI, 1.2-2.2; P = .002) and CVC malfunction (HR = 2.0; 95% CI, 1.6-2.4; P < .001). Increased risk of CVC-related VTE was found in patients with a prior history of VTE (HR = 23; 95% CI, 4-127; P < .001), multilumen CVC (HR = 3.9; 95% CI, 1.8-8.9; P = .003), and leukemia (HR = 3.5; 95% CI, 1.3-9.0; P = .031). Children with PICCs had a significantly higher incidence of catheter-related VTE, CLABSI, and CVC malfunction over TLs. The results suggest that pause be taken prior to placing CVCs, especially PICCs, due to the serious complications they have been shown to cause.
•PICCs have an increased rate of VTE over TLs in children.•Children with a history of thrombosis, leukemia, or a multilumen CVC have an increased risk of VTE.
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Abstract only
Introduction:
Pulmonary embolism (PE) is a rare but potentially severe disease. Strategies for treatment in adults are evolving to increasingly include local thrombolysis and ...thrombectomy, in addition to mainstay treatment of anticoagulation (AC). Neither the incidence of pediatric PE nor contemporary evidence on treatment have been well studied, so this study addresses these knowledge gaps by describing PE patients and their treatment outcomes.
Methods:
A retrospective multicenter cohort study was performed using patients ≤18 years with PE at US hospitals contributing data to the Pediatric Health Information Systems Database from 1/1/2015-9/1/2021. This study 1) described the clinical characteristics of PE patients, 2) examined trends in treatment strategies, and 3) used multivariable models to examine the relationship between treatment and outcomes (in-hospital mortality, length of stay (LOS), and adjusted costs of hospitalization).
Results:
In total, 3148 unique patients with PE were studied (54% female, median age 15 years). Most patients (63%) had at least one comorbid condition, the most common being congenital heart disease (25%). Most patients received anticoagulation only (88%), 7% underwent systemic thrombolysis, and 5% underwent local thrombolysis and/or thrombectomy. In-hospital mortality was 7.5%, with 62% of patients requiring ICU admission, and 7.4% receiving extracorporeal membrane oxygenation. Median (IQR) LOS was 10 days (21) and median cost was $54,026 (145,231). Use of thrombectomy and thrombolysis did not increase over time (p=0.98). In multivariable analysis, receipt of local thrombolysis and/or thrombectomy was associated with lower mortality (adjusted OR: 0.54, p=0.03). Systemic thrombolysis (β=1.73, p<0.001) and local thrombolysis and/or thrombectomy (β=1.35, p=0.003) were associated with higher costs than AC alone, without significant associations between treatment and LOS.
Conclusion:
Pediatric PE is associated with high mortality and healthcare utilization, reflecting the medical complexity of the patients. Rates of local thrombolysis and thrombectomy remain low, and further study is required to elucidate which patients may benefit from such procedural management.
Unprovoked venous thromboembolism (VTE) is rare in pediatrics. Current recommendations for anticoagulation duration after unprovoked VTE differ for pediatric and adult populations.
This ...single-center, retrospective cohort study aimed to determine the incidence rate of recurrent VTE in children and adolescents with unprovoked VTE, evaluate the potential risk factors for recurrence, and describe the anticoagulation regimens and bleeding in this population.
Children with an index, unprovoked VTE at the age of 1 to <21 years between 2003 and 2021 were included. The time to recurrent VTE and anticoagulation duration were summarized using Kaplan-Meier estimators. Clinical covariates were assessed for association with recurrence using stratified Kaplan-Meier curves and univariate Cox proportional hazards regression.
Eighty-five children met the inclusion criteria, and there were 26 recurrent events in 250 person-years of follow-up (incidence rate = 104 95% CI, 71-153 per 1000 person-years). An age of ≥12 years at index VTE (hazard ratio HR, 7.56; 95% CI, 1.60-35.83) and inherited thrombophilia (HR, 2.28; 95% CI, 1.05-4.95) were significantly associated with recurrent VTE. Female sex had a nonstatistically significant decreased hazard of recurrence (HR, 0.56; 95% CI, 0.25-1.27). Duration of anticoagulation was variable, with a median duration of 274 days (IQR, 101-2357) for outpatient therapeutic anticoagulation. Twelve of the 26 (46%) recurrent events occurred while anticoagulation was prescribed.
The incidence rate of recurrent VTE in pediatric patients with a prior unprovoked VTE is high, particularly for adolescents and those with inherited thrombophilia. Therefore, future research should focus on the efficacy of prolonged anticoagulation for this population.
•There are little data to guide unprovoked pediatric venous thromboembolism (VTE) management.•This single-institution study evaluated the incidence rate of recurrent VTE after unprovoked VTE.•There is a high incidence rate of recurrent VTE in pediatric patients with prior unprovoked VTE.•Age ≥ 12 years at index VTE and inherited thrombophilia are associated with recurrent VTE.
Background: Venous thromboembolism (VTE) is the second most common contributor to harm in hospitalized pediatric patients.The presence of a central venous catheter (CVC) remains the most potent risk ...factor for the development of VTE in children. Children with chronic illnesses often require multiple CVCs throughout their lifetime. There is limited evidence regarding either risk factors for recurrent VTE with subsequent CVC placement or efficacy of secondary prophylaxis.
Methods: We performed a single center retrospective cohort study and included subjects from 0-18 years of age with an initial CVC-associated VTE (CVC-VTE) that occurred between 1-1-2003 to 12-31-2013. Subject data was collected from the initial CVC-VTE event until either the end of the study period (9-30-2014) or a recurrent VTE event. Data collection included demographics, CVC details (total number of CVCs placed during the study period, line type, and duration), underlying medical conditions (acute and chronic), thrombophilia, and anticoagulation regimens. During the study period, our clinical practice included secondary VTE prophylaxis with enoxaparin for subsequent CVCs as long as a contraindication to anticoagulation did not exist. The enoxaparin dosing for prophylaxis dosing varied throughout the study period. The association between CVC-VTE recurrence and VTE risk factors for the first subsequent CVC was assessed using logistic regression. A forward stepwise selection approach was used for model building. Variables with a p-value < 0.15 on univariate analysis were included in model building as well as variables deemed clinically significant.
Results: During the study period, 432 subjects had an initial CVC-associated VTE with a mean follow-up time of 27.3 ± 29.6 months. 222 (51.4%) had 1 or more additional CVCs placed with a mean of 1.8 ± 1.3 CVC per subject (Figure 1). For the entire cohort, 111/432 (25.7%) had a recurrent CVC-VTE. Limiting the analysis to the first additional CVC placement, 76/222 (34%) patients had a recurrent CVC-VTE. 67/222 (30%) of patients did not receive secondary prophylaxis. Demographics and distribution of VTE risk factors are listed in Table 1. On univariate analyses, congenital heart disease (OR 8.22; 95% CI 1.74, 38.8) and TPN dependence (OR 5.28; 95%CI 1.12, 25) were associated with an increased risk for VTE recurrence with the first additional CVC placement (Table 2). On multivariable analysis, none of the VTE risk factors remained statistically significant (Table 2).
Conclusions: Over half (222/432) of all children with CVC-VTE in our study required a subsequent CVC. In those who had a subsequent CVC, 50% (111/222) experienced a recurrent CVC-VTE. This is an extremely high risk of thrombosis in a heterogeneous group of children with chronic medical conditions. On multivariable analysis we were unable to identify additional risk factors for VTE recurrence. While the use of secondary prophylaxis either prophylactic (0.76, 95%CI 0.31-1.88) or full dose (0.58, 95%CI 0.28-1.2) had associated odds ratios consistent with a decrease in VTE recurrence, they did not meet statistical significance. A history of a prior CVC-VTE is likely the strongest risk factor for recurrent CVC-VTE. This very high risk group (patients with prior CVC-VTE who require a subsequent CVC) is an ideal population to target in future interventional studies.
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Raffini:Green Cross Inc: Consultancy; CSL Behring: Consultancy; Bayer: Consultancy; Genetech: Consultancy.
The objective of this article is to review the particular tendencies as well as specific concerns of bleeding and clotting in children with critical cardiac disease.
MEDLINE and PubMed.
Children with ...critical heart disease are at particular risk for bleeding and clotting secondary to intrinsic as well as extrinsic factors. We hope that this review will aid the clinician in managing the unique challenges of bleeding and clotting in this patient population, and serve as a springboard for much needed research in this area.
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