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Published on: October 12, 2012
Prophylactic Enoxaparin Against Catheter-Associated Thrombosis in Postoperative Cardiac Children: An Interrupted Time
Gabriela I Centers1, Kerry M Hege2, Mara E Nitu1
1Division of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN.
Insights
Implementing an enoxaparin protocol for postoperative cardiac children significantly increased prophylaxis use. This led to a notable reduction in catheter-associated thrombosis rates, suggesting enoxaparin
Area of Science:
- Pediatric Cardiology
- Pharmacology
- Critical Care Medicine
Background:
- Effectiveness of pharmacologic prophylaxis against catheter-associated thrombosis in pediatric cardiac patients remains unclear.
- Central venous catheters are common in postoperative cardiac children, increasing thrombosis risk.
Purpose of the Study:
- To evaluate the compliance and outcomes of a prophylactic enoxaparin protocol in postoperative cardiac children.
- To assess the impact of a quality improvement initiative on enoxaparin use and thrombosis rates.
Main Methods:
- Interrupted time series analysis of data from November 2014 to December 2018 in a pediatric cardiac ICU.
- Inclusion criteria: Children ≤18 years old with congenital heart disease, postoperatively with central venous catheter.
- Protocol implementation in January 2016 with a target anti-Xa range, revised in February 2017 for infants <1 year.
Main Results:
- Analyzed 780 hospitalizations from 636 children across three periods: preprotocol, protocol implementation, and protocol revision.
- Median percentage of catheter-days on enoxaparin increased significantly post-protocol implementation (90% increase).
- Median thrombosis rates per 1,000 catheter-days decreased by 67% immediately after protocol implementation and 11% overall.
Conclusions:
- The temporal association between increased enoxaparin use and decreased thrombosis rates suggests the protocol's effectiveness.
- Prophylactic enoxaparin may be effective in reducing catheter-associated thrombosis in this high-risk pediatric population.
Objectives:
The effectiveness of pharmacologic prophylaxis against catheter-associated thrombosis in children is unclear. We evaluated the compliance and outcomes associated with a prophylactic enoxaparin protocol in postoperative cardiac children.
Design:
The protocol was implemented as a quality improvement initiative and then analyzed using interrupted time series method. Data collected from November 2014 to December 2018 were divided into preprotocol (period 1), protocol implementation (period 2), and protocol revision (period 3).
Setting:
A 12-bed academic pediatric cardiac ICU.
Patients:
Children less than or equal to 18 years old with congenital heart disease admitted postoperatively with central venous catheter in situ for greater than or equal to 1 day.
Interventions:
Before 2016, prophylactic enoxaparin was administered according to physician preference. In January 2016, an enoxaparin protocol was implemented with a goal anti-Xa range of 0.25-0.49 international units/mL. Protocol was revised in February 2017 to increase the starting dose by 25% for infants less than 1 year old.
Measurements And Main Results:
We analyzed 780 hospitalizations from 636 children. Median percentage of catheter-days on prophylactic enoxaparin was 33% (interquartile range [IQR], 23-47%), 42% (IQR, 30-51%), and 38% (IQR, 35-52%) in periods 1-3, respectively. Percentage of catheter-days on enoxaparin showed immediate increase of 90% (95% CI, 17-210%) between periods 1 and 2 and sustained increase of 2% (95% CI, 0.3-4%) between periods 2 and 3. Median rates of thrombosis per 1,000 catheter-days were 5.8 (IQR, 0-9.3), 3.8 (IQR, 0-12), and 0 (IQR, 0-5.3) in periods 1-3, respectively. Rate of thrombosis showed immediate decrease of 67% (95% CI, 12-87%) between periods 1 and 2 and sustained decrease of 11% (95% CI, 2-18%) between periods 1 and 3.
Conclusions:
The temporal association between increase in percentage of catheter-days on enoxaparin and decrease in rate of thrombosis suggests the effectiveness of prophylactic enoxaparin.
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