Pediatr Surg Int (2013) 29:445–449 DOI 10.1007/s00383-013-3259-y
ORIGINAL ARTICLE
Management of peripherally inserted central catheter associated deep vein thrombosis in children Alessandra C. Gasior • E. Marty Knott Shawn D. St. Peter
•
Accepted: 7 January 2013 / Published online: 23 January 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Abstract Introduction No protocol exists for prophylaxis or therapeutic management of peripherally inserted central catheter (PICC) related deep venous thrombosis (DVT) in children. Currently, very few patients are provided prophylaxis for DVT. In this study, we analyzed our current practice of PICC placement to identify the frequency of DVT, analyze risk factors and determine current treatment patterns in order to determine the need for protocols. Methods The dataset was retrospectively collected from January 1, 2000 to December 31, 2011. Patients with an upper extremity PICC were assessed for subsequent DVT formation. Variables included: demographics, co-morbidities, method of DVT diagnosis, treatment course, and recurrence. Results There were 1,289 PICC placements, with 24 (1.9 %) per line events of DVT in 23 patients, of which 3 had recent surgery, 2 had sepsis, 1 had a family history of clots, and 2 had a malignancy. All but one was symptomatic. Diagnosis was made in 92 % by ultrasound, the remaining with CT. No patients had prophylaxis. Of the seven patients who underwent hypercoagulable work-up, three were positive. 15 patients were treated with enoxaparin, 5 patients were treated with heparin, 2 treated with tissue plasminogen activator and 2 were observed. 84 % were treated with long-term enoxaparin for a mean of 3.3 months with 54 % proven clot resolution and 1 patient had recurrence of UE DVT. Conclusions The risk of DVT with PICC placement is small in children and prophylaxis can probably be reserved A. C. Gasior E. Marty Knott S. D. St. Peter (&) Department of Pediatric Surgery, Children’s Mercy Hospital and Clinics, 2401 Gillham road, 64108 Kansas, MO, USA e-mail:
[email protected]
for those with previous DVT or known hypercoagulable state. Keywords
PICC DVT Pediatric Upper extremity
Introduction Peripherally inserted central line catheters (PICC) are the most common mode of central venous access in children and infants [1]. It is estimated that 8.3–33 % of patients in the neonatal intensive care units receive a PICC line [2, 3]. However, these silastic catheters are not without risk. Complication rates including breaks, occlusion and infection have been seen ranging from 20 to 50 % in children requiring long term treatment [4, 5]. With this increased use of PICC lines, a multi-center study from 2001 to 2007 reveals an increase in the diagnosis of venous thromboembolism at pediatric hospitals 34–58 per 10,000 admissions [6]. Additionally, infants less than 1 year old and adolescents account for the majority [7]. Currently, no protocol exists for prophylaxis or therapeutic treatment of deep venous thrombosis (DVT) in the pediatric population. As DVT is an escalating problem in the pediatric population where PICC lines are becoming the routine for intravenous access, we sought to determine the incidence of upper extremity PICC line DVT, examine the current management and identify risk factors for DVT formation at our institution.
Methods After Internal Review Board approval (#11-120-170) a retrospective review was conducted from January 1, 2000
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through December 31, 2011. Inclusion criteria were patients less than 21 years who underwent an upper extremity PICC line placement at our institution. Variables recorded included patient demographics, duration of PICC line, presence of clinical symptoms, diagnosis of partial or complete DVT, method of diagnosis, presence of hypercoagulable work up, initial treatment, long-term therapy, resolution of clot and recurrence rate. Partial DVT was defined as vascular filling defect with residual flow in the vein. Complete DVT was defined as complete occlusion of the vein lumen. Fisher’s exact test and unpaired t test were used, where appropriate. Significance was determined as P \ 0.05.
Results During the study period 1,289 upper extremity PICC lines were placed. Of those PICC lines, there were 24 (1.9 %) per line events of DVT formation occurring in 23 patients. There was no difference in age, gender, or duration of PICC (Table 1). In five cases, the primary diagnosis for hospital admission was the DVT. Risk factors included recent operation in three patients, malignancy in two patients, prior thrombosis in one patient, and family history of thrombosis in one patient. No patients were on DVT prophylaxis. One patient had a pulmonary embolism (PE). The mean duration of PICC line before DVT diagnosis was 9.7 days. 92 % of patients were clinically symptomatic from the DVT, presenting with upper extremity pain, edema, errythema, or even facial swelling. 92 % were diagnosed by doppler ultrasound; the remainders were diagnosed by CT scan. 19 patients had occlusive thrombi and 5 patients had non-occlusive thrombi. Nearly 80 % of the clots extend into the subclavian vein by US exam. 88 % of the PICC lines were removed after diagnosis. Of the three patients who did not have the PICC removed after diagnosis, one patient was a neonate with no other access. The PICC was left in place with a low molecular weight heparin drip therapy. The patient was followed by daily ultrasounds, which showed the clot to decrease in size. The patient’s affected extremity was monitored clinically and over time the swelling and erythema decreased Table 1 Comparison of DVT per PICC line events No DVT (n = 1265)
DVT (n = 24)
Age (years)
7.0
7.9
0.56
Gender
M 50.2 %
M 33.3 %
0.15
Duration of PICC (days)
18.8
9.7
0.22
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P value
significantly. In another patient, the PICC line was unable to be removed due to the clot. After 3 days of systemic heparin therapy, the PICC line was able to be dislodged. Interestingly, this patient was also the one patient in the study with a PE. The fourth patient had a terminal illness and the parents chose not to treat the thrombosis and to keep the PICC in place. Only seven patients underwent a hypercoagulable workup, and three were positive. Treatment was initiated in 22 of the 24 PICC thrombi, 15 with enoxaparin, 5 with heparin drip, and 2 with tissue plasminogen activator. 19 patients were treated with long-term anticoagulation with a mean duration of 3.3 months, of which 16 patients were treated with enoxaparin and 3 were treated with warfarin. Of the five patients not treated with long-term anticoagulation, one patient was not treated due to an intraventricular hemorrhage after 5 days of lovenox therapy. She was followed with ultrasounds and found to have resolution of the clot. Another patient was not given anticoagulation due to a recent history of intracranial hemorrhage and transplant kidney hematoma formation after her transplant surgery. A third patient was not treated with anticoagulation at the parents request due to terminal illness, as mentioned above. A fourth patient was treated with removal of PICC alone, due to a history of a bleeding disorder. The fifth patient did not receive anticoagulation as the clot had resolved after removal, as seen on a followup ultrasound obtained 2 days after the catheter was withdrawn. Recurrence of UE DVT occurred in one patient 6 months after the initial diagnosis. The recurrence occurred on the contralateral UE following another PICC line placement. This patient did not undergo a hypercoagulable workup at the time of the initial thrombus and she was not placed on prophylactic anticoagulation prior to the recurrence. two other patients had subsequent lower extremity DVT. Follow-up imaging with ultrasound in 20 cases documented resolution of clot in 13. The mean follow-up ultrasound that demonstrated resolution of clot was 2 months. Complication of anticoagulation occurred in one patient who developed an intraventricular hemorrhage 5 days after starting enoxaparin, which was subsequently stopped. No patients had any long-term sequelae from the DVT. When the patients were grouped based on age distribution between neonates, 1-to12-years-old and teenagers, the peak incidence was found in patients aged 1–12 years (Fig. 1). Most infants had the primary diagnosis of infection, whereas 1-to12-year- old and teenagers had other as the primary diagnosis. Only the 1-to12-year-old were found to have a positive hypercoagulable state. Additionally, the 1-to12-year-olds and teenagers were less likely to have resolution of clot (Table 2).
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Fig. 1 Age distribution of UE DVT
Table 2 Age distribution and risk factors in UE PICC DVT Infants (n = 5)
1–12 years (n = 14)
Teenagers (n = 5)
Fig. 2 DVT prophylaxis protocol
Primary diagnosis Infection
4
3
–
Recent surgery
1
–
–
Cancer
–
1
–
Others
–
10
5
0
3
0
Initial treatment
4
14
4
Clot resolution
4
7
2
Hypercoagulable state
Discussion The reported incidence of traditional central catheter related DVT in the pediatric population varies from 11 to 50 % with the highest risk at 4 days after insertion [8, 9]. The incidence of symptomatic PICC line DVT ranges from 0 to 5.3 % [10]. Neurological ICU patients were reported to have a PICC line associated UE DVT rate of 8.4 % [11]. These data suggest that PICC lines have a lower rate of thrombosis than centrally inserted catheters. However, the reported incidence of DVT is thought to be underestimated as only the symptomatic patients undergo imaging studies and are subsequently diagnosed with clots [12]. Moreover, the incidence of DVT is as high as 9.3 % when all patients with a PICC line were imaged, with only 1 out of 20 patients presenting with clinical indications of a DVT [13]. Our study shows that with upper extremity PICC lines, 92 % of the patients were symptomatic from the DVT with swelling, pain and erythema. However, we expect to have
underestimated the incidence in our population given the majority of patients were imaged only based on clinical symptoms. Our institutional incidence of UE PICC related DVT is 1.9 % per line event, with a mean PICC line duration of 9.7 days at DVT diagnosis. Others have shown more complications are typically seen in low body weight (\12.5 kg) infants [14]. This may be expected as the catheter to vein size ratio is more similar to standard central lines. However, our average age of diagnosis was 8 years old and no patients were\2.5 kg. When the ages were distributed into neonates, 1-to12-years old and teenagers, ages 1–12-year-old were found to be the most common age group in our study. One report documented the use of enoxaparin has increased over the past decade to 53 % [7]. Our institution reflects this shift in DVT management as well, with 63 % of the patients being treated with enoxaparin. This is likely due to the ease of subcutaneous administration compared to continuous infusion as well as simplicity of titration with less monitoring. Only 29 % of our patients with a DVT underwent a hypercoagulable work-up, nearly half of which were positive. Perhaps, a standardized protocol for patients with DVTs should include hypercoagulable studies to determine future risk for DVT in our young patients. The average duration of long-term anticoagulation therapy in our study was 3 months, however for patients who underwent follow-up ultrasound, the average date of
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Fig. 3 Upper extremity PICC DVT treatment protocol
clot resolution was 2 months. Perhaps an ultrasound at 2 months post-diagnosis demonstrating resolution of clot would terminate anticoagulation therapy sooner.
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Guidelines from the American College of Chest Physicians (ACCP) give a strong recommendation for no chemoprophylaxis for children with central venous catheters
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due to the scarcity of supporting evidence, as well as increased risk for bleeding complications [15]. The risk of a bleeding complication, although small, is present. Our one patient complication was an intraventricular hemorrhage after 5 days of enoxaparin therapy, which was immediately stopped. The ACCP gives weak recommendation that treatment be individualized, based solely upon extrapolation of adult data. While the risk for DVT in the pediatric population is low, our study suggests that DVT prophylaxis should be utilized for patients with previous history of thrombosis or known hypercoagulable state (Figs. 2, 3). A protocol for placement, work-up and treatment may streamline care and improve resource utilization.
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