Deep Venous Thrombosis

Over the years, the Ped EM Morsels have addressed several conditions that historically are considered to be “adult” problems, but are actually concerns that we may need to have for children also (ex, Cholecystitis, Cholelithiasis, Pulmonary Embolism, Glaucoma, Sigmoid Volvulus, Cecal Volvulus). Occasionally the risk factors and presentation may be different in children compared to adults, but it is also important for us to keep these conditions on our Differential Diagnosis Lists for children. Let’s take a minute to review another item that we should not prematurely disregard – Deep Venous Thrombosis:

Deep Venous Thrombosis: Basics

  • Deep Venous Thrombosis (DVT) = blood clot in the deep veins of the limbs, chest, abdomen, or cerebral sinuses [Jaffray, 2018; Rodriguez-Fanjul, 2011]
  • The majority of cases of occur in children who have been recently / are hospitalized. [Jaffray, 2018]
  • Two peaks in incidence:
    • Less than 1 month of age (often in NICU)
    • Adolescents
  • Presentations [Jaffray, 2018; Rodriguez-Fanjul, 2011]
    • Symptoms depend on region involved.
      • Extremities – pain and swelling, sometimes warmth and redness (may be mistaken for an infection)
      • Superior Vena Cava – SVC syndrome with swelling and discoloration for the head, neck, and upper chest
      • Intra-Abdominal Deep Veins – Vague abdominal pain, splenomegaly, GI Bleeding, Hematuria
      • Cerebral Sinus – headache, vomiting, seizures
    • Signs may also include catheter malfunction.
      • Difficulty infusing medication
      • Difficulty aspirating blood sample
  • May lead to Long-Term Sequelae
    • Post-Thrombotic Syndrome [Jaffray, 2018; Avila, 2016; Avila, 2014]
      • Valvular damage leads to chronic venous insufficiency.
      • Leads to chronic pain and swell.
      • May also have reduced exercise tolerance, altered sensation, skin ulcerations.
    • Pulmonary Embolism
    • Increased mortality! [Steen, 2019]
  • With improved care of ill children, the rate of DVTs in children is increasing.

Deep Venous Thrombosis: Risk Factors

  • Virchow’s Triad (Stasis, Vessel Injury, and Hyper-coagulable states) still applies in children… but what leads to those issues may be different.
  • Central Venous Catheters [Dhir, 2019; Steen, 2019; Jaffray, 2018; Menendez, 2016]
    • Most common risk factor
    • Often in children with other risk factors (ex, hospitalization, Trauma, Immobility, Surgery, Chronic illness like Short Gut).
    • Femoral lines are high risk. [Gray, 2012]
    • Multilumen also high risk… essentially larger caliber catheters. [Gray, 2012]
  • Patient/Disease Related Conditions [Jaffray, 2018]
    • Cancers (especially leukemia and lymphoma) – High Risk!
    • Congenital heart diseaseHigh Risk!
    • Sepsis and Bacteremia [Pruitt, 2016]
    • Intestinal failure (especially when have PICC line for TPN)
    • Neuromuscular disease (due to immobility)
    • Nephrotic syndrome (loss of anti-coagulant proteins!)
    • Thrombophilia – both acquired and inherited
    • Traumatic Injuries [Alturki, 2019; Leeper, 2017]
    • Anatomic anomalies
    • Hospitalized children often have multiple risk factors.
  • Medications [Jaffray, 2018]
    • Estrogens, Oral Contraceptions
    • Steroids
    • Asparaginase

Deep Venous Thrombosis: Management

  • Diagnosis [Jaffray, 2018]
    • Doppler ultrasound is the most common diagnostic tool.
      • Compression and doppler flow in addition to direct visualization are means to detect DVT.
      • Bedside Ultrasound performed in the ED can also be useful. [Tay, 2012]
      • Ultrasound is less reliable for upper extremity DVTs.
    • MR Venogram and CT Venogram are occasionally required.
    • MR Venogram is study of choice for Cerebral Venous Thrombosis.
  • Therapy [Jaffray, 2018]
    • Unfractionated Heparin
      • Short half-life and has reversal agent.
      • Monitored by aPTT levels.
    • Low Molecular Weight Heparins
      • Most commonly prescribed in children.
      • As effective as unfractionated heparin; has less bleeding.
      • Given BID in children.
      • Monitored by antifactor Xa assay.
    • Direct Thrombin Inhibitors
      • IV Bivalirudin or IV Argatroban blocks thrombin’s effects.
      • Monitored by aPTT level.
    • Selective Anti-thrombin-Dependent Factor Xa Inhibitor
      • Fondaparinux is given once daily subcutaneously.
      • Monitored by antifactor Xa assay.
    • Vitamin K Antagonists
      • Coumadin most commonly used example.
      • Monitored via INR.
      • Must be started with another anticoagulant (like a Heparin) as Protein C and Protein S are also Vitamin K dependent; thus, transient hypercoagulability can result after starting coumadin.
    • Direct Oral AntiCoagulants (DOACs)
      • In adults, DOACs are approved for DVT therapy.
      • In children, studies are still being done to determine efficacy and safety.

Moral of the Morsel

  • Virchow’s Triad applies to Children too! Consider the risk factors before dismissing the potential for DVT.
  • Swelling and Redness does not always equal infection! DVT may present similarly to an infection in an extremity.
  • DVTs are not just in the arms and legs. Think about all of the deep veins and how that may alter the presenting symptoms.

References

Dhir A1, DeMarsh S2, Ramgopal A3, Worley S3, Auron M3, Hupertz V3, Onimoe G3. Central Venous Line Associated Deep Vein Thrombosis in Hospitalized Children. J Pediatr Hematol Oncol. 2019 May 13. PMID: 31094910. [PubMed] [Read by QxMD]
Steen EH1, Lasa JJ2, Nguyen TC2, Keswani SG3, Checchia PA2, Anders MM4. Central Venous Catheter-Related Deep Vein Thrombosis in the Pediatric Cardiac Intensive Care Unit. J Surg Res. 2019 Sep;241:149-159. PMID: 31026793. [PubMed] [Read by QxMD]
Alturki N1, Alkahtani M2, Daghistani M2, Alyafi T2, Khairy S2, Ashi M2, Aljuffri A2. Incidence and risk factors for deep vein thrombosis among pediatric burn patients. Burns. 2019 May;45(3):560-566. PMID: 31018912. [PubMed] [Read by QxMD]
Abood KK1, Paul MR2, Kuo DJ2. Deep Vein Thrombosis in a Young, Healthy Baseball Catcher: A Case Report and Review of the Literature. J Pediatr Hematol Oncol. 2019 May;41(4):321-323. PMID: 29401105. [PubMed] [Read by QxMD]
Jaffray J1, Young G1. Deep vein thrombosis in pediatric patients. Pediatr Blood Cancer. 2018 Mar;65(3). PMID: 29115714. [PubMed] [Read by QxMD]
Leeper CM1, Neal MD, McKenna C, Sperry JL, Gaines BA. Abnormalities in fibrinolysis at the time of admission are associated with deep vein thrombosis, mortality, and disability in a pediatric trauma population. J Trauma Acute Care Surg. 2017 Jan;82(1):27-34. PMID: 27779597. [PubMed] [Read by QxMD]
Pruitt LG1, Mosley JC1, Lasseigne RF Jr1. Bacteremia and Deep Vein Thrombosis in an Infant. J Emerg Med. 2016 May;50(5):e227-30. PMID: 26954105. [PubMed] [Read by QxMD]
O’Brien SH1, Yee DL2, Lira J3, Goldenberg NA4,5, Young G3. UNBLOCK: an open-label, dose-finding, pharmacokinetic and safety study of bivalirudin in children with deep vein thrombosis. J Thromb Haemost. 2015 Sep;13(9):1615-22. PMID: 26180006. [PubMed] [Read by QxMD]
Avila ML1, Duan L1, Cipolla A1, Kim A1, Kahr WH2, Williams S1, Brandão LR1. Postthrombotic syndrome following upper extremity deep vein thrombosis in children. Blood. 2014 Aug 14;124(7):1166-73. PMID: 24957144. [PubMed] [Read by QxMD]
Tay ET1, Stone MB, Tsung JW. Emergency ultrasound diagnosis of deep venous thrombosis in the pediatric emergency department: a case series. Pediatr Emerg Care. 2012 Jan;28(1):90-5. PMID: 22217897. [PubMed] [Read by QxMD]
Gray BW1, Gonzalez R, Warrier KS, Stephens LA, Drongowski RA, Pipe SW, Mychaliska GB. Characterization of central venous catheter-associated deep venous thrombosis in infants. J Pediatr Surg. 2012 Jun;47(6):1159-66. PMID: 22703787. [PubMed] [Read by QxMD]
Greene LA1, Goldenberg NA. Deep vein thrombosis: thrombolysis in the pediatric population. Semin Intervent Radiol. 2012 Mar;29(1):36-43. PMID: 23449161. [PubMed] [Read by QxMD]
Rodríguez-Fanjul J1, Trenchs V, Muñoz-Santanach D, de Sevilla MF, Toll T, Blanch J, Luaces C. Deep vein thrombosis: rare cases of diagnoses in a pediatric emergency department. Pediatr Emerg Care. 2011 May;27(5):417-9. PMID: 21546806. [PubMed] [Read by QxMD]
Mitchell LG1, Male C. Outcome measures in interventional trials for prevention or treatment of venous thrombosis in the pediatric population. Semin Thromb Hemost. 2011 Oct;37(7):840-7. PMID: 22187408. [PubMed] [Read by QxMD]
Radecki RT1, Gaebler-Spira D. Deep vein thrombosis in the disabled pediatric population. Arch Phys Med Rehabil. 1994 Mar;75(3):248-50. PMID: 8129573. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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