Thrombotic disease in critically ill children
Michael C. McCrory, MD; Kenneth M. Brady, MD; Clifford Takemoto, MD; Joseph D. Tobias, MD; R. Blaine Easley, MD
Objectives: To summarize a) epidemiology of arterial and venous thromboembolism, pulmonary embolism, and deep venous thrombosis in children; b) the risk factors for thrombosis in the pediatric intensive care unit; c)diagnostic techniques for arterial/venous thromboembolism; and d) the current recommendations for management and prevention of thromboembolic disease in critically ill children. Data Source: Literature review, using National Library of Medicine PubMed and the following terms: arterial, venous thromboembolism; deep venous thrombosis; pulmonary embolism; thrombosis; as well as citations of interestfrom these articles. Study Selection: Both pediatric and adult literature addressing thrombotic disease were reviewed. Data Extraction and Synthesis: Articles were chosen for more extensive discussion when containing prospective studies, guidelines for practice, or data in critically ill patients. When data in children were unavailable, applicable data in adults were referenced. Due to the paucity ofdata in critically ill children, available adult and pediatric data were combined with institutional experience to provide suggestions for current practice and future inquiry. Conclusions: Increasing awareness regarding the recognition and current approaches to management and prevention of thromboembolic disease in children is needed among pediatric intensivists, so outcome of theselife-threatening processes might be improved. (Pediatr Crit Care Med 2011; 12:80 – 89) KEY WORDS: venous thromboembolic disease; pulmonary embolus; arterial thromboembolism; pediatric; thrombotic disease
hrombotic disease in the critically ill is an increasingly recognized cause of morbidity and mortality in this vulnerable patient population. Although the mechanisms for pediatric venous and arterialthrombosis are incompletely understood, recent studies have identiﬁed both genetic and disease-related factors that increase the risk for thrombotic disease in critically ill children. The most important risk factors in pediatric thrombosis include vascular catheters, congenital heart disease, and malignancy; this interaction of risk factors and clinical scenarios common to the pediatric intensivecare unit (PICU) will be discussed and current strategies for evaluation and treatment of critically ill children affected
with arterial or venous thrombosis will be reviewed.
Clinical Presentations and Epidemiology of Venous and Arterial Thrombosis
Infants and children may present with either venous or arterial vascular thrombotic disease. Venous thromboembolic disease (VTE) in illchildren may present as deep venous thrombosis, pulmonary embolus (PE), cerebral sinovenous thrombosis, or as thrombosis in any other organ system (Table 1). Commonly reported symptoms include pain/discomfort, swelling, loss of patency/function of vascular catheters, hypoxia, respiratory distress, and neurologic dysfunction. Monagle et al (1) reported data on a prospective cohort of 405 infants andchildren with VTE. Overall, mortality was 16%, with a VTE-related mortality rate of 2.2%. Morbidity included recurrence of thrombosis in 8% of patients and postphlebitic syndrome with chronic pain, swelling, and limb discoloration in 12.4%. Although the risk of VTE in immobile adults post surgery has been known for decades, few reports of VTE in children exist before the 1960s (2). More recent datafrom the National Hospital Discharge Survey in the United States, as
From the Departments of Anesthesiology and Critical Care Medicine (MCM, KMB, RBE) and Pediatrics (MCM, KMB, CT, RBE), Johns Hopkins Hospital, Baltimore, MD; and the Departments of Anesthesiology and Pediatrics (JDT), University of Missouri—Hospital and Clinics, Columbia, MO. The authors have no potential conﬂicts of interest to...