Pediatric emergency medicine trisk 2252 2252
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initiated with a bolus injection of 50 to 75 units/kg followed by a constant infusion of 20
units/kg/hr for children older than 1 year and 28 units/kg/hr for neonates and infants.
Adjust the UFH dose according to readily available nomograms ( Table 93.13 ).
Anticoagulation with LMWH is equal in safety and efficacy to UFH; however, a
therapeutic level can often be more quickly achieved with LMWH. UFH has the
advantage of a short half-life, so its effects are more easily reversible in the setting of a
bleed or need for a procedure. While direct oral anticoagulants (DOACs) are now firstline anticoagulation for many adult VTE indications, they are still in pediatric clinical
trials.
When venous or arterial thrombosis is extensive or occludes blood flow, threatening a
patient’s life or the integrity of a limb or vital organ, infusion of a thrombolytic agent
can result in the dissolution of the thrombus and reestablishment of blood flow.
Thrombolytic agents such as tissue plasminogen activator (tPA), streptokinase, and
urokinase have been used extensively in adult practice for decades, but tPA is the agent
of choice in pediatric patients. For maximum effectiveness in the appropriate clinical
setting, tPA is given as soon as possible after the symptoms begin and the extent of
vascular occlusion is documented. Therapy can be administered systemically or directed
to the distal end of the thrombosis by catheter placement. Typical infusion rates range
from 0.1 to 0.5 mg/kg/hr, but total dose and infusion duration are individualized.
Unanswered questions regarding thrombolysis in children include whether concomitant
heparin infusion is safe, how long therapy can be safely administered, and how to best
evaluate the degree of thrombolysis. The thrombolytic state is monitored by
prolongation of the PT and aPTT, reduction in fibrinogen, and rise in the concentration
of fibrin degradation products or d-dimer. The major risk of thrombolytic therapy is
bleeding; therefore, thrombolysis is contraindicated in patients who have had recent
abdominal or brain surgery.
Clinical Indications for Discharge or Admission
For patients with uncomplicated DVT, outpatient management is possible if the
resources to teach the patient/family how to administer LMWH are available and shortinterval follow-up with hematology is assured. For patients requiring UFH infusion or
with PE or stroke, inpatient management is appropriate.
