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Vanderbilt Pediatric Hematology Thrombosis Protocol . 4 / 11 / 12. Robert F. Sidonio, Jr. MD, MSc . . Yes. Candidates for anticoagulation thromboprophylaxis Elevated lipoprotein (a) Protein S/C deficiency Antithrombin deficiency Antiphospholipid antibody syndrome

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Vanderbilt Pediatric Hematology Thrombosis Protocol

4/11/12

Robert F. Sidonio, Jr. MD, MSc.

Yes

  • Candidates for anticoagulation thromboprophylaxis
  • Elevated lipoprotein (a)
  • Protein S/C deficiency
  • Antithrombin deficiency
  • Antiphospholipid antibody syndrome
  • DVT or PE x 2 without inherited thrombophilia
  • IBD/Lupus patient hospitalized for acute illness without acute bleeding
  • Cancer and history of thrombus
  • Inherited thrombophilia patients the following scenarios:
    • Acute illness requiring hospitalization
  • Bone fracture that does not allow full ambulation
  • Spinal Cord trauma without bleeding
  • Any surgery that does not allow full ambulation within 12 hours
  • Transient DVT risk factors
  • Line placed during acute illness
  • Osteomyelitis
  • Cellulitis
  • Myositis
  • Pneumonia
  • Sepsis
  • Exogenous estrogen (OCPs)

Acute venous or

arterial thrombosis

See thrombolysis protocol

Does patient meet inclusion and exclusion criteria for tPA?

Obtain pediatric hematology consult

Yes

  • 6 weeks
  • Stop anticoagulation if ALL:
  • Complete resolution on U/S
  • Transient risk factor resolved
  • Normalized 2 of 3 inflammatory markers (CRP, D-dimer, FVIII)

Non-occlusive DVT

Is there an indication for thrombolysis?

No

No

Baseline labs: CBC, PT, PTT, fibrinogen activity,

FVIII activity, D-dimer (quantitative) and CRP

-Defer hypercoaguability workup until outpatient

-Start Enoxaparin or UFH

_____________________________________________

Start Enoxaparin:

<3 month old 1.7mg/kg/dose BID

3-12 months old 1.5mg/kg/dose BID

1-5 years old 1.2mg/kg/dose BID

6-18 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/dose

Goal PTT 65-100 seconds (Consider only 24-72 hrs) and anti-FXa 0.35-0.7

  • 3 months
  • Stop anticoagulation if ALL:
  • Complete resolution on CT/MR
  • Transient risk factor resolved
  • Normalized 2 of 3 inflammatory markers (CRP, D-dimer, FVIII)
  • Indications for thrombolysis
  • Strong 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

Cerebral sinovenous thrombosis

Length of therapy?

  • 6 months
  • Stop anticoagulation if ALL:
  • Complete resolution on CT/MR
  • Transient risk factor resolved
  • Normalized 2 of 3 inflammatory markers (CRP, D-dimer, FVIII)

Occlusive SVC, IVC or iiofemoral DVT

  • 6 months
  • Stop anticoagulation if ALL:
  • Complete resolution on CT/MR
  • Transient risk factor resolved
  • Normalized 2 of 3 inflammatory markers (CRP, D-dimer, FVIII)
  • Inclusion Criteria for tPA
  • Symptoms present <14 days
  • Thrombus site and extent confirmed by objective imaging
  • No more than 48 hours of UFH or LMWH for this thrombus
    • For 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

Pulmonary embolus

  • Consider long term anticoagulation
  • Single Ventricle Physiology
  • Indefinite Coumadin with goal INR 2-3
  • Lupus
  • If thrombus + antiphospholipid antibody consider indefinite anticoagulation
  • Cancer
  • ALL – treatment until resolution of clot (3m), prophylaxis until maintenance phase
  • Solid tumor - treatment until resolution of clot (3m), prophylaxis until remission
  • Clinic follow-up
  • Every 6 weeks for labs, physical exam and possible imaging
  • Repeat CT/MRI q3 months until resolution or total 9 months for brain thromboses
  • Repeat Ultrasound q6 weeks until resolution or total 9 months for peripheral thromboses
  • Clinic thrombosis labs (every visit)
  • CBC, FVIII activity, D-dimer (quantitative), CRP, BMP and PT/INR (if on Coumadin)
  • Defer hypercoaguable evaluation until off Coumadin >2 weeks
  • Hypercoaguable evaluation only to be sent as outpatient
  • PE: Send HYC panel + homocysteine + lipoprotein(a)
  • DVT: Send HYC panel + homocysteine

Key

UFH: Unfractionated Heparin

LMWH: Low molecular weight Heparin

CNS: Central Nervous System

tPA: Tissue Plasminogen Activator (usually alteplase)

gtt: drip

HIT: Heparin induced thrombocytopenia

PT: Prothrombin time INR: International normalized ratio

HYC panel: Activated protein C resistance ratio (with reflex FVL PCR), protein C/S activity, antithrombinactivity, PT gene miutation+ LUP panel.

LUP panel: Thrombin time, dRVVT ratio (with mix if positive), STAClot LA, Anticardiolipin antibodies and Beta-glycoprotein antibodies

  • Other considerations
  • Consider Coumadin as outpatient with education and enrollment in Coumadin Clinic.
  • Avoid insufloncatheters.