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Pulmonary Infarction Treatment & Management

  • Author: Lennox H Huang, MD, FAAP; Chief Editor: Michael R Bye, MD  more...
 
Updated: Jan 16, 2015
 

Medical Care

Medical therapy centers on providing initial cardiopulmonary support, anticoagulation to prevent clot extension, and thrombolysis in the rare event of pulmonary embolism (PE) that leads to massive cardiorespiratory failure. When able, acquired risk factors such as central venous lines should be addressed. Much of the information regarding treatment of pulmonary embolism in children has been derived from that on adults.

Deciding how to treat a venous thrombosis that may lead to a pulmonary embolism is difficult. A survey of Canadian pediatric intensivists reported 4 patient factors commonly used to determine if a venous thrombosis was clinically important: clinical suspicion of a pulmonary embolism, symptoms, detection of thrombosis on clinical examination, and presence of an acute or chronic cardiopulmonary comorbidity that affects the patient's ability to tolerate a pulmonary embolism.[3]

Anticoagulation

Anticoagulation should be started in patients without contraindications (active bleeding). Systemic anticoagulation should be started with unfractionated or low molecular weight heparin (LMWH) to achieve an antifactor Xa level of 0.5-1 U/mL or, in the case of unfractionated heparin, activated partial thromboplastin time (aPTT) levels of twice the control value. Therapy should continue for 5-10 days.

Long-term anticoagulation should continue with LMWH for as long as 6 months to achieve a target antifactor Xa level of 0.5-1 U/mL. Alternatively, oral therapy with warfarin can be used to achieve an international normalized ratio (INR) of 2-3. If oral therapy is used, dosing should begin with initial systemic anticoagulation, with discontinuation of heparin on day 5.

Studies suggest that attempts to achieve a higher INR with warfarin are associated with an increased risk of bleeding without commensurately reducing the risk of new clot formation; therefore, aiming for an INR of 2-3 is recommended. levels of more than 3 are generally unnecessary. Patients with the antiphospholipid syndrome may require INRs of more than 3.

Thrombolysis

This should be considered only if a large embolus is present in the pulmonary vasculature or in the setting of massive cardiac or pulmonary failure. Small case series have shown thrombolytic therapy can be safely used in pediatric patients with high risk venous thromboses.[20] Potential benefit must be weighed against the significant risk of bleeding.

Supportive care

Pharmacologic support of the cardiovascular system may be necessary. Dopamine and dobutamine are the usual inotropic agents. Mechanical ventilation may be necessary both to provide respiratory support and as adjunctive therapy for a failing circulatory system.

Children with sickle cell disease who present with pulmonary symptoms require treatment with a macrolide and cephalosporin antibiotic. Their clinical status should be closely monitored in order to anticipate those children who may develop acute chest syndrome.[11]

Transfusion with packed RBCs (either simple or exchange) improves oxygenation immediately, helping to break the vicious cycle outlined above.

Transfer

Transfer to an appropriate institution for further workup and therapy. Generally, this is a tertiary center in view of the rarity of embolic disease in children.

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Surgical Care

Surgical interventions in the management of pulmonary embolism consist primarily of embolectomy. Inferior vena caval filters have been used to prevent recurrent emboli, but few data are available regarding their use in children.

Embolectomy

Few data are available regarding the use of surgical embolectomy in children. Consider embolectomy in the setting of massive cardiac failure when time is insufficient for natural or pharmacologic thrombolysis or if thrombolysis is contraindicated.

Vena caval filters

Otherwise known as Greenfield filters, these are placed surgically in the inferior vena cava (IVC) and prevent further emboli from reaching the pulmonary circulation.

Indications for IVC filters include a contraindication to anticoagulation and recurrent PE despite adequate anticoagulation.

Historically, IVC filters have been limited to larger adolescent patients. Filter placement in younger patients has increased with the development of retrievable filters but is still limited to large centers with specific technical expertise.[21]

Complications include migration of the filter, sepsis, and misplacement of the filter.

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Consultations

Consider consultations with the following specialists:

  • Pulmonologist: A pulmonologist is often consulted before the true diagnosis is made because of the nonspecific nature of the symptoms.
  • Cardiologist: Consultation with a cardiologist is warranted to rule out a cardiac etiology for the presenting symptoms and signs and to perform ECHO and pulmonary angiography.
  • Cardiothoracic surgeon: If embolectomy is considered, consultation with a cardiac surgeon is mandatory.
  • Hematologist: A hematologist can suggest an appropriate workup for a procoagulant defect and can recommend an anticoagulation regimen. Consultation with a hematologist is essential in children with sickle cell disease. A free clinical consultation service for complex cases of thromboembolism in children is available for clinicians by calling The Pediatric Thrombosis Program at 1-800-NO-CLOTS (1-800-662-5687).
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Diet

No specific diet is contraindicated. However, excessive weight should be avoided in those with a history of pulmonary embolism.

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Activity

Activity should not be limited. Mobilization should be encouraged in those with a history of pulmonary embolism or those at risk of having a pulmonary embolism. Patients taking anticoagulants should avoid high-impact sports.

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Contributor Information and Disclosures
Author

Lennox H Huang, MD, FAAP Associate Professor and Chair, Department of Pediatrics, McMaster University School of Medicine; Chief of Pediatrics, McMaster Children's Hospital

Lennox H Huang, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association for Physician Leadership, Canadian Medical Association, Ontario Medical Association, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Barry J Evans, MD Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Michael R Bye, MD Professor of Clinical Pediatrics, State University of New York at Buffalo School of Medicine; Attending Physician, Pediatric Pulmonary Division, Women's and Children's Hospital of Buffalo

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

G Patricia Cantwell, MD, FCCM Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami Leonard M Miller School of Medicine/ Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Director, Palliative Care Team, Holtz Children's Hospital; Medical Manager, FEMA, South Florida Urban Search and Rescue, Task Force 2

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

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