Surgeon General's Workshop on Deep Vein ThrombosisThrombosis In The Pediatric Patient: Unique Risk Factors, Diagnosis & Management Issues1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 19 | 20 Thrombosis In The Pediatric Patient: Unique Risk Factors, Diagnosis & Management Issues. Surgeon General’s Workshop on DVT May 8-9, 2006 Bethesda, Maryland Marilyn J. Manco-Johnson, MD & Neil A. Goldenberg, MD Departments of Pediatrics and Medicine, Mountain States Regional Hemophilia & Thrombosis Center University of Colorado at Denver & Health Sciences Center & The Children's Hospital, Denver, CO, US SLIDE 2: DVT is the Most Common Blood Clot in Children (n=84) Pie chart showing the following percentages:
SLIDE 3: Although Rare, DVT is a Health Risk During Childhood, Especially for Newborn Infants & Adolescents
DVT is an Important Cause of Death in Children
DVT Has a High Risk of Pulmonary Embolism in Children
SLIDE 5: DVT in Children Can Be Recurrent
8.1% (33/405) median 2.8 yrs
8% (8/100) after 1 year 18% (18/100) after 7yrs 10% (51/505) Composite SLIDE 6: Children with DVT are More Likely to Have Multiple Thrombophilia Traits Mountain States Regional Hemophilia & Thrombosis Center Number of Children Seen 2001-2003 293 Thrombosis 131 Family Study 162 Thrombophilia testing:
DVT recurrence is more likely with multiple thrombophilia traits! SLIDE 7: LMWH Dosing Is More Variable in Children & Requires More Monitoring
SLIDE 8: Post Thrombotic Syndrome (PTS) Causes Disability in Children & Adolescents Stage1: Swelling: DVT age 16 years; FVL, OCP Stage 2: Visible Collaterals DVT age 14 yrs; APA, prolonged bus ride Stage 3: Induration, hyperpigmentation DVT age 13 years; FVL, APA Stage 4: Stasis ulcers; DVT age 10 yrs; PC, tibial fracture 12.4% (50/405) median 2.8 yrs Monagle P, et al Pediatr Res 2000;47:763-6 59% (10/17) pain 41% (7/17) abn PE IVC Hausler M, Arch Dis Child 2001;85:228-33. 63% (96/153) Kuhle S, et al. Thromb Res 2003;111:227-33. 70% (23/33) Van Ommen, et al J Thromb Haemost 2003;1:2516-22 29% (179/608) Composite SLIDE 9: DVT Therapy is Frequently Delayed in Children Due to Under-Recognition. Two charts showing Treatment Delay Results in Poor DVT Resolution and Long-Term Pain. Results of 81 DVT in Children treated with Anticoagulation SLIDE 10: Teen Age is a Risk Factor for PTS Line chart showing Teen Age is a Risk Factor for PTS SLIDE 11: Overweight Predisposes to PTS in Children & Teens Photos showing how Overweight Predisposes to PTS in Children & Teens (January 2004 and October 2004) Stage 3: Skin induration, venous eczema Overweight Predisposes to PTS in Children & Teens 88% rate of overweight in children with PTS Overweight children have RR of 7 for PTS SLIDE 12: Inflammation is the Most Common Risk Factor; DVT without a Risk Factor is Rare in Children Pie chart showing
SLIDE 13: Inflammatory Markers* at Diagnosis Predicts a Poor Outcome of Thrombosis in Children Probability of a Poor DVT Outcome: Positive Likelihood Ratio 6.1 All children
Children with inflammation
* FVIII, DD, Goldenberg, et al NEJM, 2004;351:1081-8 SLIDE 14: The Newborn Infant Has a Unique Hemostatic Balance: BLEEDING
THROMBOSIS
SLIDE 15: Thrombosis May Be Devastating in Neonates Photos of thrombosis in Neonates SLIDE 16: Children Have an Excellent Chance for Recovery From Severe DVT Now 18 years old, this "Gifted & Talented" HS Senior with severe protein C deficiency (compound heterozygous, <1%) is going to college. SLIDE 17: Outcome of In Utero Thrombosis with Severe Thrombophilia is Good with Treatment [Photo] CXR on Infant with Respiratory Infection PMH: normal pregnancy, labor and delivery; well until acute respiratory illness FH: negative for bleeding, thrombosis Left: Organized IVC clot, left adrenal hemorrhage SLIDE 18: Critical Issues in DVT in Children
SLIDE 19: DVT is the Most Common Blood Clot in Children (n=84) Time-Limited Risk Factors: Trauma, surgery, immobility Indwelling Catheters Infection, Post infectious APA Surgically Correctible Congenital Heart Disease Leukemia, Cancer, Chemotherap Steroids On-Going Risk Factors: Genetic Thrombophilia Primary or Secondary APAS Inflammatory Diseases Prosthetic Cardiac Valves Sickle Cell Anemia Pie chart showing
SLIDE 20: Clot Formation is Accelerated in the Newborn Picture of CloFAL Assay Picture of newborn and adultCloFAL Assay |
