Management Of Neonatal Thrombosis Research Articles

Two Unusual Cases of Spontaneous Thrombosis in Neonates: Management and Outcome

Neonatal thrombosis usually occur as a complication of an indwelling central vascular catheter. Here we report two unusual cases of spontaneous thrombosis in neonates. In case 1, baby had a left atrial thrombus diagnosed soon after birth serendipitously by echocardiography. Since the thrombus was highly mobile with risk of embolization, he was given thrombolytic therapy. Thrombolysis resulted in prompt resolution of the thrombus without any complication. In case 2, baby had a chronic left axillary artery thrombosis that had occurred in utero. He presented at birth with features of limb ischemia. He was given anticoagulant therapy for three months. Though the limb perfusion and movements normalized, he developed shortening of the limb due to chronic ischemia. To conclude, due to non-availability of standard guidelines and scarcity of existing literature, management of these neonates is arbitrary. Owing to the rapidly expanding neonatal intensive care that contemplates more such cases, it is time to formulate separate guidelines for the management of thrombosis in neonates.

Epidemiology, diagnosis and management of neonatal thrombosis: a single-center cohort study.

The incidence of neonatal venous and arterial thrombosis ranges from 6.9 to 15/1000 neonatal ICU (NICU) admissions, and is likely an underestimate based on population demographics, frequency of surveillance and vascular catheterization. This retrospective study involving 234 infants reviewed the epidemiology, diagnosis, and management of neonatal thrombosis in a single, tertiary care institution over more than 10 years. The incidence of thrombosis was 25/1000 NICU admissions, with a preterm to term infant ratio of 1.5 : 1 and a slightly higher proportion of male sex (55.1%). The mean (range) gestational age and birth weight was 33.8 weeks (23-41.6) and 2360 g (512-5890). The median age (IQR) of thrombus diagnosis was 7 (3-17) days. Portal vein thrombosis was most prevalent (59.4%) compared with other sites of thrombosis. Almost three-quarter (171/234; 73.1%) of the thrombotic episodes were line-related, while infection and surgery were associated with 19.7% (46/234) and 10.7% (25/234), respectively. Twenty patients (8.3%) were screened for thrombophilia and 3 were positive; 2 for antithrombin deficiency, 1 for factor V Leiden gene mutation. Subjects were followed with imaging for 3 months with a treatment duration, mean (IQR) of 33.5 (10.8-42.5) days. Complete clot resolution was significantly higher in the anticoagulation group (48%; 17%; P = 0.03) compared with untreated patients. No group difference was noted for partial thrombus resolution (33.3%; 12.4%; P = 0.313). Anticoagulation halted thrombus progression (2.6 versus 12.4%; P = 0.025) and fewer treated patients failed to attend follow-up visits (6.5 versus 18.6%; P = 0.022). Well designed, multicenter prospective studies with larger sample sizes are required to confirm these findings.

Epidemiology, Diagnosis and Management of Neonatal Thrombosis

Introduction: Current research on neonatal thrombosis is limited. It relies heavily on individual case reports and much of the data is extrapolated from the adult scientific literature. The aim of this descriptive study is to review the epidemiology, diagnosis and management of neonatal thrombosis at a single tertiary care institution. Methods: This is a retrospective study of apatients admitted to McMaster Children's Hospital, neonatal intensive care unite from 2005 to 2018. Data on patient demographics, diagnostic imaging, thrombophilia testing, co-morbidities, treatment, outcomes were collected from health records. Results: A total of 242 neonatal patients were included. The distribution of 251 thrombotic episodes was: 144 portal vein, 15 cerebral sino-venous, 12 cardiac, 2 pulmonary embolisms, 5 renal vein, 40 extremity and central venous and 13 arterial. Additionally, 20 cases categorized as miscellaneous, consisted of clots in sites such as the basilic vein or umbilical artery, among other locations. Male and female percentages were 55% and 45%, respectively. Preterm to term infant ratio was 1.5:1. The average age at diagnosis was 13.2 days. 70% of thrombotic episodes were line-related, while infection and surgery were associated with 19% and 12% of episodes, respectively. 52% of the patients were blood group O. 30% of the patients received initial anticoagulation treatment, while the rest were managed conservatively. There was a trend towards higher rate of complete clot resolution in patients who received anticoagulation (48%) compared to those who did not (40%). Conclusion: This is one of the largest, single institution, epidemiologic studies of neonatal thrombosis. In our group of patients, portal vein thrombosis was most prevalent compared to other sites of thrombosis and catheterization was the commonest risk factor. There was a trend towards improved resolution with anticoagulation. Further prospective studies are required to confirm these findings. Disclosures No relevant conflicts of interest to declare.

Antithrombotic treatment in neonates and children.

Despite the increasing incidence of venous thromboembolic disease in pediatric patients, it remains a rare complication in childhood. Particularly neonates and adolescents are at risk for development of venous thrombosis. Spontaneous thrombotic events are sporadic, the majority of children have multiple coexisting risk factors, including central venous catheter, asphyxia, congenital heart disease, infection, malignancy, surgery and hypovolemia. Most thrombi are diagnosed by ultrasonography. Recommendations for management of pediatric thrombosis are typically extrapolated from adult studies, despite many differences between adults and children, including developmental hemostasis. This review will focus on the management of venous thrombosis in neonates and children, and discuss the use of the available antithrombotic agents in both age categories with reference to those differences.

RETRACTED: Central venous catheterization and thrombosis in newborns: update on diagnosis and management

RETRACTION

Antithrombotic Therapy in Neonates and Children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

Neonates and children differ from adults in physiology, pharmacologic responses to drugs, epidemiology, and long-term consequences of thrombosis. This guideline addresses optimal strategies for the management of thrombosis in neonates and children. The methods of this guideline follow those described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. We suggest that where possible, pediatric hematologists with experience in thromboembolism manage pediatric patients with thromboembolism (Grade 2C). When this is not possible, we suggest a combination of a neonatologist/pediatrician and adult hematologist supported by consultation with an experienced pediatric hematologist (Grade 2C). We suggest that therapeutic unfractionated heparin in children is titrated to achieve a target anti-Xa range of 0.35 to 0.7 units/mL or an activated partial thromboplastin time range that correlates to this anti-Xa range or to a protamine titration range of 0.2 to 0.4 units/mL (Grade 2C). For neonates and children receiving either daily or bid therapeutic low-molecular-weight heparin, we suggest that the drug be monitored to a target range of 0.5 to 1.0 units/mL in a sample taken 4 to 6 h after subcutaneous injection or, alternatively, 0.5 to 0.8 units/mL in a sample taken 2 to 6 h after subcutaneous injection (Grade 2C). The evidence supporting most recommendations for antithrombotic therapy in neonates and children remains weak. Studies addressing appropriate drug target ranges and monitoring requirements are urgently required in addition to site- and clinical situation-specific thrombosis management strategies.

Thrombosis in Infants and Children

During the last decade much progress has been made toward better understanding of the underlying reasons causing thromboembolism in children. A considerable number of acquired and hereditary thrombotic risk factors have been identified which may also have an impact on therapeutic decisions and prognosis concerning outcome and the risk of a second event. However, indications for therapeutic interventions, such as thrombolysis and prophylactic anticoagulation with respect to the different clinical conditions and their combination with other risk factors, are not yet well defined. The following article describes the causes, clinical presentation and management of thrombosis in neonates, infants and older children, focusing on the clinically most relevant conditions.