eMedicine Specialties > Pediatrics: General Medicine > Hematology

Thromboembolism: Follow-up

Author: Scott C Howard, MD, Associate Professor, University of Tennessee College of Medicine; Associate Member, Department of Oncology, Director of Clinical Trials, International Outreach Program, St Jude Children's Research Hospital
Coauthor(s): Philip M Monteleone, MD, Associate Professor, Department of Pediatrics, Division of Oncology, University of Pennsylvania and Children's Hospital of Philadelphia
Contributor Information and Disclosures

Updated: Jan 13, 2009

Follow-up

Further Inpatient Care

  • Admit patients with thromboembolisms to a pediatric or adolescent ward or ICU, depending on their respiratory and neurologic status.
  • Anticoagulation is begun with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH), followed by oral anticoagulation with warfarin. Children required daily follow-up until their international normalized ratio (INR) is more than 2 on 2 successive days.
  • Obtain daily CBC count, prothrombin time (PT), and activated partial thromboplastin time (aPTT) values while children are inpatients. If LMWH is used, obtain an anti–activated factor X (anti-Xa) level and adjust the dose to achieve a level of 0.5-1 U/mL.

Further Outpatient Care

  • Monitoring of patients receiving oral anticoagulation
    • For patients receiving oral anticoagulation, monitor the PT and/or INR within 3 days of their discharge from the hospital. Always check the INR 5-7 days after adjusting the dose. After the INR is 2-3 (or 2.5-3.5 in patients with mechanical valves) on 2 successive measurements obtained 1 week apart, the monitoring interval can be lengthened to every 2 weeks. In general, the INR is monitored monthly. Children taking warfarin for more than a year should be monitored for decreased bone density.
    • Point-of-care monitoring of oral anticoagulation may be available for home use or at specialized pediatric anticoagulation clinics. Point-of-care monitoring is especially helpful for children who require indefinite oral anticoagulation as part of treatment for congenital heart disease or inherited hypercoagulable disorders.
    • The patient or family should inform the physician of any changes in diet or medications.
  • Duration of therapy
    • The duration of therapy depends on the underlying problem. Children with mechanical heart valves or recurrent TE require anticoagulation indefinitely. Children with TE and persistent risk factors may be treated for 3 months then switched to low-dose warfarin until the risk factor is no longer present. Uncomplicated DVT can be treated for 3-6 months.
    • Monitor children who are taking LMWH for more than 4 weeks; obtain a CBC count every 1-4 weeks to look for heparin-induced thrombocytopenia and an anti–activated factor X level (every 2-6 wk once a therapeutic level is achieved). Enoxaparin may accumulate over time, and dosage adjustments may be necessary.

Deterrence/Prevention

  • Patients should avoid participating in contact sports and weight lifting while they are receiving anticoagulation.
  • Sexually active female adolescents should use some form of birth control, preferably not oral contraceptives if they are receiving oral anticoagulants.

Complications

Potential complications of thromboembolism include the following:

  • Recurrent thrombosis
  • Pulmonary embolism
  • Postthrombotic syndrome
  • Bleeding
  • Death

Prognosis

  • Many children with thromboembolism have a persistent underlying risk factor, such as congenital heart disease.
  • Recurrent thrombosis occurs in as many as 19% of children.
  • The mortality rate associated with pulmonary embolism (PE) or arterial ischemic stroke is 6-20%.

Patient Education

  • If a child is receiving oral anticoagulation, review the vitamin K content of various foods with the family.
  • Clearly define activity restrictions, especially with adolescents.

In/Out Patient Medications

  • A patient's medication may include heparin or LMWH, oral anticoagulants, thrombolytic agents, and, occasionally, antiplatelet agents (for arterial thrombosis).
  • Avoid giving antiplatelet agents to children receiving anticoagulation unless they are absolutely necessary.
  • Monitor the patient's INR more closely than usual if his or her medications or diet changes.

Miscellaneous

Medicolegal Pitfalls

Because thromboembolism is uncommon and because its symptoms are often nonspecific in children, a high index of suspicion is required.

Special Concerns

Neonatal thrombosis is a special concern. 

  • Neonates have multiple risk factors for thromboembolism, including prematurity, sepsis, and frequent use of central arterial and venous lines.
  • Also, developmental differences in their hemostatic systems create difficulties in management.
  • Neonates have low levels of antithrombin and plasminogen, which cause relative resistance to heparin and thrombolytic agents, respectively.
  • In addition, newborns need 11 times the usual concentration of urokinase given to adults and 5 times the usual concentration of tissue plasminogen activator to achieve the same rate of plasminogen activation.
 


More on Thromboembolism

Overview: Thromboembolism
Differential Diagnoses & Workup: Thromboembolism
Treatment & Medication: Thromboembolism
Follow-up: Thromboembolism
Multimedia: Thromboembolism
References
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Further Reading

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Keywords

thrombosis, clots, thrombus, embolism, thrombus embolism, TE, thrombi, blood clot, venous thromboembolism, VTE, deep venous thrombosis, deep vein thrombosis, DVT, pulmonary embolism, PE, postthrombotic syndrome, post-thrombotic syndrome, PTS, central venous catheter, CVC, stasis, CNS thrombosis, renal vein thrombosis, antiphospholipid antibody syndrome, APLA, stroke, obesity, nephrotic syndrome, systemic lupus erythematosus, acute lymphoblastic leukemia

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Contributor Information and Disclosures

Author

Scott C Howard, MD, Associate Professor, University of Tennessee College of Medicine; Associate Member, Department of Oncology, Director of Clinical Trials, International Outreach Program, St Jude Children's Research Hospital
Scott C Howard, MD is a member of the following medical societies: American Society of Pediatric Hematology/Oncology
Disclosure: Nothing to disclose.

Coauthor(s)

Philip M Monteleone, MD, Associate Professor, Department of Pediatrics, Division of Oncology, University of Pennsylvania and Children's Hospital of Philadelphia
Philip M Monteleone, MD is a member of the following medical societies: American Society of Hematology
Disclosure: Nothing to disclose.

Medical Editor

J Martin Johnston, MD, Associate Professor of Pediatrics, Mercer University School of Medicine; Director of Pediatric Hematology/Oncology, Backus Children's Hospital; Consulting Oncologist/Hematologist, St Damien's Pediatric Hospital
J Martin Johnston, MD is a member of the following medical societies: American Society of Pediatric Hematology/Oncology
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

James L Harper, MD, Associate Professor, Department of Pediatrics, Division of Hematology/Oncology and Bone Marrow Transplantation, Associate Chairman for Education, Department of Pediatrics, University of Nebraska Medical Center; Assistant Clinical Professor, Department of Pediatrics, Creighton University; Director, Continuing Medical Education, Children's Memorial Hospital; Pediatric Director, Nebraska Regional Hemophilia Treatment Center
James L Harper, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for Cancer Research, American Federation for Clinical Research, American Society of Hematology, American Society of Pediatric Hematology/Oncology, Council on Medical Student Education in Pediatrics, and Hemophilia and Thrombosis Research Society
Disclosure: Nothing to disclose.

CME Editor

Samuel Gross, MD, Professor Emeritus, Department of Pediatrics, University of Florida; Clinical Professor, Department of Pediatrics, University of North Carolina; Adjunct Professor, Department of Pediatrics, Duke University
Samuel Gross, MD is a member of the following medical societies: American Association for Cancer Research, American Society for Blood and Marrow Transplantation, American Society of Clinical Oncology, American Society of Hematology, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Chief Editor

Robert J Arceci, MD, PhD, King Fahd Professor of Pediatric Oncology, Department of Oncology, Division of Pediatric Oncology, Johns Hopkins University School of Medicine
Robert J Arceci, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Pediatric Society, American Society of Hematology, and American Society of Pediatric Hematology/Oncology
Disclosure: Nothing to disclose.

 
 
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