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Pulmonary Thromboses in Pediatric Acute Respiratory Distress Syndrome
Magalie Caudron1, Tanya Holt2, Geoff DE Cuvelier3
1Division of Pediatric Critical Care, University of British Columbia, Vancouver, British Columbia, Canada.
Insights
Pulmonary thrombosis is an underrecognized complication in pediatric acute respiratory distress syndrome (ARDS). A proposed diagnostic algorithm and early heparin treatment may improve outcomes for these critically ill children.
Area of Science:
- Critical Care Medicine
- Pediatric Pulmonology
- Hematology
Background:
- Pediatric acute respiratory distress syndrome (ARDS) presents significant management challenges, including prolonged hospital stays and high mortality rates.
- Thromboembolic pulmonary embolism and in situ pulmonary artery thrombosis are potentially underappreciated thrombotic complications in pediatric ARDS.
- While risk factors like coagulopathy and endothelial injury are common in pediatric ARDS, pulmonary thromboses are primarily described in case reports.
Purpose of the Study:
- To propose a diagnostic algorithm for early identification of pulmonary thromboses in pediatric ARDS patients.
- To suggest a management strategy involving targeted heparin treatment and right ventricular afterload reduction.
- To improve clinical outcomes by identifying and treating this specific patient subgroup.
Main Methods:
- Development of a diagnostic algorithm triggered by specific physiological parameters: alveolar dead space fraction ≥ 0.25, a 50% increase in dead space/tidal volume, or central venous saturation ≤ 60% over 24 hours.
- Interpretation of data from animal, pediatric, and adult studies to inform the algorithm's development.
- Consideration of targeted heparin treatment and right ventricular afterload reduction as therapeutic interventions.
Main Results:
- The proposed algorithm aims to facilitate timely and accurate diagnosis of pulmonary thromboses in pediatric ARDS.
- Early identification and intervention may lead to improved clinical outcomes.
- Data on anticoagulation efficacy and safety in children with pulmonary embolism are limited compared to adults.
Conclusions:
- Pulmonary thromboses may be an underdiagnosed cause of morbidity and mortality in pediatric ARDS.
- The proposed diagnostic algorithm and treatment strategy offer a potential pathway to improve patient care.
- Further research is needed to validate the algorithm and establish optimal anticoagulation protocols for pediatric ARDS patients with pulmonary thrombosis.
Abstract:
Pediatric ARDS continues to be a management challenge in the ICU with prolonged hospitalizations and high mortality. Thromboembolic pulmonary embolism and in situ pulmonary artery thrombosis might represent underappreciated thrombotic processes for a subset of these patients. Although well described in the adult literature, descriptions of pulmonary thromboses with pediatric ARDS are limited to case reports. However, many risk factors for pulmonary thromboses are present in children with ARDS (eg, coagulopathy, endothelial injury, central venous catheters, concomitant inflammatory diseases), suggesting a much higher incidence is plausible. Based on an interpretation of animal, pediatric, and adult data, we propose a diagnostic algorithm to facilitate a timely and accurate diagnosis. Observing an alveolar dead space fraction ≥ 0.25, or either a 50% increase in physiologic dead space/tidal volume or a central venous saturation ≤ 60% over 24 h, triggers the algorithm. Together with targeted heparin treatment and right ventricular afterload reduction, clinical outcomes might improve if this particular patient subgroup can be identified early. While anticoagulation is recommended in adults with confirmed pulmonary embolism and low early mortality risk, data for children are limited.
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