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Outcomes using a clinical practice pathway for the management of pulse loss following pediatric cardiac
Andrew C Glatz1, Rachel Keashen, Julie Chang
1Division of Cardiology, Children's Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania.
Insights
A clinical practice pathway effectively manages postcatheterization pulse loss in children. Early anticoagulation and ultrasound diagnosis lead to nearly 90% thrombus resolution within 12 weeks.
Area of Science:
- Pediatric Cardiology
- Vascular Medicine
- Clinical Practice Improvement
Background:
- Lack of standardized protocols for postcatheterization arterial thrombus management leads to practice variation.
- Pediatric cardiac catheterization carries risks, including pulse loss due to thrombus formation.
Purpose of the Study:
- To evaluate the effectiveness of a clinical practice pathway (CPP) for managing postcatheterization pulse loss in pediatric patients.
- To assess the impact of early anticoagulation and ultrasound-guided therapy on thrombus resolution.
Main Methods:
- Retrospective review of prospectively collected data for quality improvement.
- Implementation of a CPP involving early anticoagulation and serial ultrasound assessments.
- Comparison of unfractionated heparin versus enoxaparin for initial anticoagulation therapy.
Main Results:
- A 5.4% incidence of pulse loss was observed post-catheterization.
- Ultrasound confirmed arterial thrombus in 85 patients, with 66 (77.6%) achieving resolution by 12 weeks.
- Enoxaparin demonstrated higher rates of achieving therapeutic anticoagulation levels compared to unfractionated heparin, with no observed bleeding complications.
Conclusions:
- A CPP for postcatheterization pulse loss is feasible and effective in pediatric patients.
- Early anticoagulation and ultrasound are crucial for diagnosis and monitoring treatment response.
- Nearly 90% of patients completing 12 weeks of therapy achieved thrombus resolution.
Objective:
Objectives To describe the results of a clinical practice pathway (CPP) for the management of postcatheterization pulse loss in a children's hospital.
Background:
Standardized approaches to the diagnosis and management of postcatheterization arterial thrombus are lacking. As a result, substantial practice variation exists.
Methods:
Data collected prospectively for quality improvement purposes were retrospectively reviewed.
Results:
Since initiation of the CPP, 93/1,672 (5.4%) catheterizations resulted in pulse loss at a median patient age and weight of 73 days (1 day-5.8 years) and 4.8 kg (2-14.1 kg). Arterial thrombus was documented by ultrasound (US) in 85. Of these, 66 resolved by 12 weeks of therapy, seven patients died, and four were lost to follow-up before completing treatment. Eight patients had persistent thrombus despite a full treatment course (89% success rate in those able to complete treatment). Of patients treated with unfractionated heparin as initial therapy, 46% (17/37) achieved a therapeutic partial thromboplastin time within 12 hr with 19% (67/343) of all levels therapeutic. As a result, the CPP was modified to use enoxaparin as first line agent, of which 57% (41/72) had a therapeutic anti-Xa level after the 2nd dose and 88% by the 4th dose. No bleeding complications were observed. A priori established process metrics were achieved.
Conclusions:
A CPP utilizing early initiation of anticoagulation and US to aid diagnosis of postcatheterization arterial thrombus and response to therapy is feasible and effective. In those able to complete up to 12 weeks of treatment, resolution occurs in nearly 90%. © 2014 Wiley Periodicals, Inc.
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