Guías para la prevención de Enfermedad Tromboembólica en pacientes pediátricos: (IV Consenso Venezolano sobre Enfermedad Tromboembólica 2008-2009)

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Abstract

La Enfermedad Tromboembolica (ETE) en la edad pediatrica ha adquirido mayor importancia, debido al aumento de su incidencia derivada de la optimizacion de tecnicas diagnosticas y terapeuticas. Los episodios de ETE en los ninos aparecen de forma brusca y el diagnostico se hace con metodos incruentos como ecografia doppler, resonancia magnetica y estudios angiograficos. Hasta hace poco no se disponia de recomendaciones especificas para el tratamiento de la ETE en el nino; en la actualidad se cuenta con esquemas terapeuticos desarrollados con base en la experiencia con adultos, adaptados a la edad pediatrica. Se revisan las principales patologias y procedimientos susceptibles de producir enfermedad tromboembolica asi como las indicaciones de los principales agentes terapeuticos, incluyendo las heparinas, los anticoagulantes orales, antiagregantes y fibrinoliticos y se dan recomendaciones de uso. Dada la morbimortalidad observada en ninos afectados por ETE, hay sobradas justificaciones para tomar una actitud activa que intente controlar el proceso y procurar que el beneficio esperado sea siempre superior al riesgo inherente al tratamiento.

Translated abstract

Thromboembolic disease (TD) in pediatric patients has gained relevance, due to an increase in its incidence, as a result of the optimization of diagnostic and therapeutic techniques. Episodes of TD in children appear abruptly and diagnosis is carried out through non-invasive methods such as doppler ecography, magnetic resonance imaging and angiography. Until recently, specific recommendations for the treatment of TD in children were unavailable; nowadays, therapeutic schemes developed on the basis of experience with adults adapted to pediatric patients are available. The main pathologies and procedures capable of causing thromboembolic disease were reviewed, as well as the indications of main therapeutic agents, including heparins, oral anticoagulants, platelet antiagregant and fibrinolytic agents. Use recommendations are given. Considering the morbimortality rate observed in children affected by TD, there are plenty of reasons to take an active role to control the process, and seek that expected benefits outweigh the inherent risks of treatment.

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Most cited references 84

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Antithrombotic therapy in neonates and children: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).

Fenella Kirkham, P Massicotte, Gabrielle deVeber … (2008)

This chapter about antithrombotic therapy in neonates and children is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs, and Grade 2 suggests that individual patient values may lead to different choices (for a full understanding of the grading, see Guyatt et al in this supplement, pages 123S-131S). In this chapter, many recommendations are based on extrapolation of adult data, and the reader is referred to the appropriate chapters relating to guidelines for adult populations. Within this chapter, the majority of recommendations are separate for neonates and children, reflecting the significant differences in epidemiology of thrombosis and safety and efficacy of therapy in these two populations. Among the key recommendations in this chapter are the following: In children with first episode of venous thromboembolism (VTE), we recommend anticoagulant therapy with either unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) [Grade 1B]. Dosing of IV UFH should prolong the activated partial thromboplastin time (aPTT) to a range that corresponds to an anti-factor Xa assay (anti-FXa) level of 0.35 to 0.7 U/mL, whereas LMWH should achieve an anti-FXa level of 0.5 to 1.0 U/mL 4 h after an injection for twice-daily dosing. In neonates with first VTE, we suggest either anticoagulation or supportive care with radiologic monitoring and subsequent anticoagulation if extension of the thrombosis occurs during supportive care (Grade 2C). We recommend against the use of routine systemic thromboprophylaxis for children with central venous lines (Grade 1B). For children with cerebral sinovenous thrombosis (CSVT) without significant intracranial hemorrhage (ICH), we recommend anticoagulation initially with UFH, or LMWH and subsequently with LMWH or vitamin K antagonists (VKAs) for a minimum of 3 months (Grade 1B). For children with non-sickle-cell disease-related acute arterial ischemic stroke (AIS), we recommend UFH or LMWH or aspirin (1 to 5 mg/kg/d) as initial therapy until dissection and embolic causes have been excluded (Grade 1B). For neonates with a first AIS, in the absence of a documented ongoing cardioembolic source, we recommend against anticoagulation or aspirin therapy (Grade 1B).

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Cerebral venous thrombosis in children: a multifactorial origin.

Barbara Zieger, Robert R. Junker, Ralf Knöfler … (2003)

The present study was performed to assess the association of prothrombotic risk factors and underlying conditions (infections, vascular trauma, immobilization, malignancies, autoimmune diseases, renal diseases, metabolic disorders, obesity, birth asphyxia, cardiac malformations, and use of prothrombotic drugs) with cerebral venous thrombosis (CVT) in children. From 1995 to 2002, 149 pediatric patients aged newborn to <18 years (median 6 years) with CVT were consecutively enrolled. In patients and in 149 age- and gender-matched children with similar underlying clinical conditions but without CVT, the factor V G1691A mutation, the factor II G20210A variant, lipoprotein(a) [Lp(a)], protein C, protein S, antithrombin, and antiphospholipid antibodies, as well as associated clinical conditions, were investigated. Eighty-four (56.4%) of the patients had at least 1 prothrombotic risk factor compared with 31 control children (20.8%; P<0.0001). In addition, 105 (70.5%) of 149 patients with CVT presented with an underlying predisposing condition. On univariate analysis, factor V, protein C, protein S, and elevated Lp(a) were found to be significantly associated with CVT. However, in multivariate analysis, only the combination of a prothrombotic risk factor with an underlying condition (OR 3.9, 95% CI 1.8 to 8.6), increased Lp(a) (OR 4.1, 95% CI 2.0 to 8.7), and protein C deficiency (OR 11.1, 95% CI 1.2 to 104.4) had independent associations with CVT in the children investigated. CVT in children is a multifactorial disease that, in the majority of cases, results from a combination of prothrombotic risk factors and/or underlying clinical condition.

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Neonatal thrombosis: report of a prospective Canadian and international registry.

Bernhard MW Schmidt, Elizabeth Andrew (1995)

We sought to obtain representative data on the risk factors, diagnosis, current management, and short-term outcome of neonatal thrombosis. A case registry was established at McMaster University. Standardized questionnaires were mailed to collaborators at participating centers every 4 to 6 months. Eighty-five level III and modified level II neonatal units in North America, Europe, and Australia were invited to join the registry. Eligible infants were born between January 1990 and June 1993. Large-vessel thrombosis was diagnosed during the first month of life or up to 44 weeks post-conception after premature birth. The clinical impression of thrombotic vessel obstruction was confirmed using at least one imaging technique. Physicians in 64 centers expressed their willingness to participate. A total of 97 cases (excluding stroke) were registered from 29 centers. Spontaneous renal venous thrombosis (n = 21) was diagnosed at a median age of 2 days. The other venous (n = 39), arterial (n = 33), and mixed (n = 4) thromboses presented later; 89% of them were associated with an intravascular catheter and 29% with systemic infection. Doppler ultrasonography was the definitive diagnostic test in 68% of cases; contrast angiography was performed infrequently (14%). A third of all patients (but 62% of infants with renal venous thrombosis) received supportive therapy only. Thrombolytic agents were prescribed for 28% of catheter-associated venous thromboses and 30% of all arterial thromboses. The remainder of the patients were given heparin. Most patients (82%) survived to hospital discharge. Mortality rates were highest among infants with aortic thrombosis or central venous line-associated thrombosis affecting the right atrium or the superior vena cava (33%). Neonatal thrombosis is diagnosed fairly rarely. With the exception of spontaneous renal venous thrombosis, almost all cases are associated with indwelling catheters. Doppler ultrasound techniques are the most popular means of confirming the diagnosis in virtually all centers. Treatment varies greatly among different centers, probably because of the lack of scientific evidence about the optimum management of affected infants.

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Author and article information

Contributors

Huníades Urbina-Medina: Role: ND

María Josefa Castro: Role: ND

Darinka De Pascuali: Role: ND

Leopoldo Córdova: Role: ND

Iván Machado: Role: ND

Journal

Journal ID (publisher): avpp

Title: Archivos Venezolanos de Puericultura y Pediatría

Abbreviated Title: Arch Venez Puer Ped

Publisher: Sociedad Venezolana de Puericultura y Pediatría (Caracas )

ISSN: 0004-0649

Publication date (Print): September 2009

Volume: 72

Issue: 3

Pages: 101-108

Affiliations

[1 ] Hospital de Niños JM de los Ríos Venezuela

[2 ] Hospital Miguel Pérez Carreño Venezuela

[3 ] Clínica Santa Sofia Venezuela

[4 ] Clínica Leopoldo Aguerrevere Venezuela

[5 ] Centro Médico Docente La Trinidad Venezuela

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Publisher ID: S0004-06492009000300006

SO-VID: 30955b35-7463-43e6-bde2-f0df48f9da39

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http://creativecommons.org/licenses/by/4.0/

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Self URI (journal page): http://www.scielo.org.ve/scielo.php?script=sci_serial&pid=0004-0649&lng=en

Guías para la prevención de Enfermedad Tromboembólica en pacientes pediátricos: (IV Consenso Venezolano sobre Enfermedad Tromboembólica 2008-2009)

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SciELO Venezuela

Most cited references 84

Antithrombotic therapy in neonates and children: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).

Cerebral venous thrombosis in children: a multifactorial origin.

Neonatal thrombosis: report of a prospective Canadian and international registry.

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