1 / 20

Thromboprophylaxis in High Risk Children.

Thromboprophylaxis in High Risk Children. E A Chalmers Royal Hospital for Sick Children Glasgow. VTE in Children & Adolescents. Scope of the problem: Disease Burden Risk Factors Outcomes Prevention: Evidence Guidelines & Strategies. Incidence of VTE in Children.

varsha
Download Presentation

Thromboprophylaxis in High Risk Children.

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Thromboprophylaxis in High Risk Children. E A Chalmers Royal Hospital for Sick Children Glasgow RSM Oct 2007

  2. VTE in Children & Adolescents. Scope of the problem: • Disease Burden • Risk Factors • Outcomes Prevention: • Evidence • Guidelines & Strategies. RSM Oct 2007

  3. Incidence of VTE in Children RSM Oct 2007

  4. Thrombosis – Age Distribution. RSM Oct 2007

  5. Distribution of Peripheral DVT & PE RSM Oct 2007

  6. Thrombosis – Risk Factors • CVL 48% • Sepsis 32% • Immobility 28% • Malignancy 26% • Surgery 21% • TPN 12% • Renal Disease 11% • FHx 10% RSM Oct 2007

  7. Thrombosis – Incidence in Children with Cancer. Author Condition Incidence Symptoms Sutor ’99 ALL(BFM-90) 1.7% 100% Nowak-Gottl ‘01 ALL(COALL) 2.5% 100% Mitchell ’01 ALL(PARKAA) 37% 1.6% Glazer ’01 Cancer 50% 25% RSM Oct 2007

  8. Thrombosis – Incidence in Children Following Trauma. • Incidence: • 0.07%-1.9% • Risk factors: • Older age. • Severity of injury (ISS>24). • Vascular injury. RSM Oct 2007

  9. Childhood VTE – Outcomes RSM Oct 2007

  10. Childhood VTE – Outcomes • Morbidity: • Symptoms related to site of thrombosis • Loss of central venous access • Recurrent thrombosis • 8% at 3 yrs – follow up of Canadian Registry. • Post thrombotic syndrome (PTS) • 9-17% in recent studies. RSM Oct 2007

  11. Prevention of VTE in Children & Adolescents. • At Risk Populations: • CVL related VTE. • Non-CVL related VTE. • Methods: • Thromboprophylaxis. • Mechanical methods. RSM Oct 2007

  12. Venous Thrombosis – Risk Factors • CVLs are the single most important risk factor for thrombosis in children RSM Oct 2007

  13. CVL/VTE – Site & Other CVL Related Features • Incidence of VTE was highest with femoral & subclavian lines (p=0.014) • Incidence of VTE was independent of: • Catheter type • Catheter size • Duration of placement (up to 50 days) RSM Oct 2007

  14. CVL Related Thrombosis. CVLTE IncidenceOdds ratio p-value SC Vein 44% 3.14 0.025 (1.2-8.5) Jugular Vein 20% Percutaneous 47% 3.5 0.011 (1.3-9.2) Cut-down 20% SCV/Percutaneous. 54% 5 0.001 (1.9-13.1) TOTAL 33% (28/85) (Male, Blood 2002) RSM Oct 2007

  15. Prevention of CVL Related VTE. LMWH(Reviparin) Standard Care Number (%) Number (%) Symptomatic VTE3/78 (3.8) 3/80 (3.8) Asymptomatic VTE 8/78 (10.3) 7/80 (8.8) Total VTE 11/78 (14.1) 10/80 (12.5) Major Bleeding 0 (0) 1/94 (1.1) Minor Bleeding 48/90 (53.3) 41/94 (43.6) Death 0 (0) 2/94 (2.1) Protekt Study, 2001 RSM Oct 2007

  16. Prevention of CVL Related VTE in Children with Leukaemia. • Study design: • RCT low dose warfarin vs control • Endpoints: • Jugular VTE at 1, 3, 6 months by USS • Enrollment: • Patients =29 Controls = 33; Total 62 • Study outcome: • Trial stopped after interim analysis • No differnce between to groups • Problems: • LD warfarin arm – • Frequent sub-therapeutic INRs Rudd, Acta Paediatrica, 2006 RSM Oct 2007

  17. ACCP Guidelines. • Recommend: • “against the use of routine systematic thromboprophylaxis for children with CVLs” • Recommend: • “consideration of thromboprophylaxis for children receiving long term home TPN using VKA” RSM Oct 2007

  18. Antithrombin for Prevention of Thrombosis in ALL • Coagulopathy during ALL therapy: • Multifactorial – effects of steriods & asparaginse. • Reduced antithrombin. • Antithrombin replacement – PARKAA study: • Antithrombin replacement during induction. • Trend towards protective clinical effect in AT treated group: VTE 28% vs 37%. • No benefit in surrogate markers of thrombin generation RSM Oct 2007

  19. Prevention of Non-CVL Related VTE. • No clinical trials. • Current practice: variable & ad hoc. • Association of Paediatric Anaesthetists. • Strategies on identifying those at high risk. • Requires consensus on who should be considered for prophylaxis. • e.g. adolescents with other risk factors. RSM Oct 2007

  20. Future Directions. • Better data collection on the incidence of VTE in specific populations. • Development of scoring systems to identify those at highest risk. • Clinical trials of thromboprophylaxis – utilization of new agents. RSM Oct 2007

More Related