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Clinical Impact of a Standardized Risk-Stratified Thromboprophylaxis Protocol for Multisystem Inflammatory Syndrome
Roma V Rajput1, Matthew P Sharron1, Padma Pavuluri1
1Children's National Hospital, Washington, DC.
Insights
A standardized thromboprophylaxis protocol for children with multisystem inflammatory syndrome (MIS-C) was feasible. The protocol led to timely anticoagulation and low rates of thromboembolism (TE) and bleeding complications in MIS-C patients.
Area of Science:
- Pediatric critical care medicine
- Hematology
- Pediatric infectious diseases
Background:
- Multisystem inflammatory syndrome in children (MIS-C) is associated with a significant risk of thromboembolism (TE).
- Standardized protocols are needed to manage TE risk in MIS-C patients.
- Thromboprophylaxis strategies require evaluation in this vulnerable pediatric population.
Purpose of the Study:
- To assess the clinical impact of implementing an institutional thromboprophylaxis protocol for pediatric patients diagnosed with MIS-C.
- To evaluate the feasibility and effectiveness of prophylactic anticoagulation in reducing TE events.
- To determine the incidence of bleeding complications associated with the thromboprophylaxis protocol.
Main Methods:
- A single-center retrospective cohort study was conducted from March 2020 to December 2021.
- The study included children under 18 years with confirmed MIS-C, managed under a standardized multidisciplinary approach.
- High-risk patients received prophylactic enoxaparin, with adjustments for target anti-Factor Xa levels and extended duration post-discharge if indicated.
Main Results:
- Of 135 MIS-C patients, 92% required ICU admission and 47% had central venous catheters.
- Prophylactic enoxaparin was initiated in 96% of high-risk patients, achieving target levels promptly.
- A low rate of symptomatic TE (0.7%) and clinically relevant nonmajor bleeding (4.2%) was observed, with no deaths.
Conclusions:
- Implementation of a standardized institutional thromboprophylaxis protocol for MIS-C is feasible and safe.
- The protocol facilitates timely initiation of prophylactic anticoagulation.
- This approach is associated with low rates of thromboembolic events and bleeding complications in pediatric MIS-C patients.
Objective:
To evaluate the clinical impact of an institutional thromboprophylaxis protocol in patients with multisystem inflammatory syndrome in children (MIS-C), who are at increased risk for thromboembolism (TE).
Study Design:
We conducted a single-center retrospective cohort study of children less than 18 years between March 2020 and December 2021. Eligible patients were confirmed with MIS-C and were managed with a standardized multidisciplinary treatment approach that included a thromboprophylaxis protocol to guide and unify clinical practice. For high-risk patients, prophylactic dose enoxaparin (target anti-Factor Xa 0.1-0.3 U/mL) was added. In high-risk patients with TE risk factors persistent at hospital discharge, thromboprophylaxis was prescribed for an additional 30 days.
Results:
Of 135 patients with MIS-C, 124 (92%) required intensive care unit stay and 64 (47%) required a central venous catheter for a median duration of 5 days (IQR, 4-7). Prophylactic dose enoxaparin was initiated in 116 out of 121 patients (96%) deemed high-risk per our protocol at a median of 1 day after admission [IQR, 0-3] achieving target levels at a median of 1 day [IQR, 1-2]. The median initial anti-Factor Xa level was 0.13 u/mL [IQR, 0.05-0.19]. One patient (0.7%) developed symptomatic noncatheter related superficial vein thrombosis requiring therapeutic anticoagulation. Thromboprophylaxis was extended for 30 days after discharge in 108 out of 135 patients (80%). Bleeding events occurred in 5 patients during hospitalization (4.2%). All bleeding events were clinically relevant nonmajor bleeding. There were no deaths.
Conclusions:
Implementation of an institutional standardized thromboprophylaxis protocol in MIS-C was feasible and led to timely initiation of prophylactic anticoagulation and low rates of TEs and bleeding complications.
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