Thromboprophylaxis in Patients with Congenital Heart Disease. Rachel Keashen, MSN, CRNP 10/19/2018

Transcription

1 Thromboprophylaxis in Patients with Congenital Heart Disease Rachel Keashen, MSN, CRNP 10/19/2018

2 No disclosures/conflicts of interest COI

3 Objectives Be able to name 2 thromboprophylaxis agents used to treat children with CHD Identify key components of physical exam when evaluating a child on anticoagulation Identify key management components when transitioning a patient from enoxaparin to warfarin

4 Why Anticoagulate? Several slides courtesy of Dr. Char Witmer

5 Clot Anti- Coagulant Platelet Plug Fibrin Lysis

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7 Inflammatory State Mechanical Support

8 Anticoagulation Drugs DRUG MONITORING REVERSAL HALF LIFE Unfractionated heparin PTT Vitamin K, FFP, protamine sulfate 100% reversed Low molecular weight heparin (enoxaparin) anti-xa Protamine sulfate Only 70% effective Warfarin INR Vitamin K, FFP, K Centra Direct oral anticoagulants NONE NONE Idarucizumab - dabigatran Neonates: 30 min hr general population hrs hrs 5-9 hrs (rivaroxaban) 12 hrs (epixiban)

9 Major bleeding rates: UFH % LMWH % Thrombocytopenia Coagulopathy Renal dysfunction Recent procedure Other source of hemorrhage Prior bleeding

10 Menorrhagia

11 Antiplatelet Therapy

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13 Antiplatelet Drugs Aspirin DRUG MONITORING REVERSAL HALF LIFE Clopidogrel (Plavix) TEG and/or platelet mapping (AA% inhibition) Platelet mapping (ADP% inhibition) None minutes BUT irreversibly binds to platelets for life of plt (7-9 days) None 6 hrs for drug, 30 minutes for metabolite (50% of drug is out of system after ~6.5 hrs)

14 Case Studies

15 Case Study Prosthetic valve MF is a 19 yo male with aortic stenosis due to a bicuspid aortic valve. He is s/p balloon valvuloplasty as an infant and now presents for an aortic valve replacement. His surgery was uneventful. A 25 mm On-X valve was placed 6/19. INR Goal 1 st 3 months: 2-3 INR Goal after 3 months: Aspirin 81 mg daily

16 Baseline Labs Hgb 13.7 Plts 248 BUN/Cr 13/0.8 PT/PTT 13.7/26.9 INR 1.09 Fibrinogen 253

17 Clinical Practice Guidelines Using a Loading Dose No Loading Dose

18 Hospital Admission INR 1.09 (baseline) Warfarin Dose mg 10 mg 10 mg 8 mg 7 mg Aspirin 81 mg 81 mg 81 mg 81 mg 81 mg

19 Clinic Visit 3 days Later INR 3.7 in clinic, no bleeding (Tuesday) Warfarin dose held that night Restart at 5mg on following day (Wednesday) Recheck INR Friday Continue daily aspirin

20 ED 6 days later Chest pain 10/10 (pressure) Abdominal pain (stabbing) Hematuria x1 Hypotensive Blurry vision Diaphoretic INR 3.42 (warfarin held x1, 4 mg x2) Hemoglobin 9.7 down from 11.2 HR: 100 BP: 113/63 RR: 20 SpO2: 98% Temp 36.8 C

21 Chest/Abd CT Scan 1. Postsurgical changes from aortic valve replacement, with moderate to large hemopericardium. 2. Small volume intraperitoneal free fluid measuring simple fluid density. 3. Hypodense lesion in the left kidney, possibly cyst. This may be evaluated with ultrasound if clinically indicated.

22 Plan Anticoagulation Issues Vitamin K versus FFP?? 1 unit FFP prior to cath lab Warfarin held, INR 2.9 following day ASA held Restart ASA??? Resume INR goal 2-3??? Plan of Care Pericardiocentesis 1200 ml of sanguinous fluid evacuated in cath lab 100 ml drained overnight, hgb stable Drain removed after 3 days Urology Consult Foley catheter placed to monitor for hematuria Removed following day with absence of further hematuria 2 days later urine clear, but heme positive Nephrology consult r/o HSP nephritis

23 Clinic, 1 month later INRs relatively stable ( 1.8 to 2.5) as outpatient, no further issues with bleeding Send home monitor application Education

24 Clinic 1 year later INR 3.88 in lab

25 Case Study enoxaparin to warfarin JQ is a 3 yo with PA/IVS s/p extracardiac fenestrated Fontan palliation. Pt presented to clinic about 6 months after palliation with symptoms of decreased exercise tolerance, decreased saturations and pleural effusion. He was admitted and after failing medical management had a stent placed in his Fontan fenestration Enoxaparin initiated that night (6/30)

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27 CHEST Enoxaparin Dosing Guidelines Age Treatment dose Prophylaxis dose <2 months 1.5 mg/kg Q12 H 0.75 mg/kg Q12H > 2 months 1 mg/kg Q12 H 0.5 mg/kg Q12 H Monagle, P. CHEST. 2012;141 Suppl; e737s. *CHOP Enoxaparin Dosing Guidelines Age Treatment dose Prophylaxis dose <3 months 1.7 mg/kg Q12 H 0.75 mg/kg Q12H 3 months to <2 years 1.2 mg/kg Q12 H 0.5 mg/kg Q12 H 2-17 years <60 kg 1 mg/kg Q12 H 0.5 mg/kg Q12 H 2-17 years >60 kg 1 mg/kg Q12 H 40 mg Q24 H <or> 30 mg Q12 H *Morbidly obese (>100 kg or BMI >30) 0.8 mg/kg Q12 H 30 mg Q12 H

28 0.5mL 31G, 5/16 1mL 27G, 1/2

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30 Cont d Continues on enoxaparin anticoagulation for about 7 months 12 mg BID entire time Gets anti-xa checked q4 weeks No bleeding complications Time to transition to warfarin Resolution of pleural effusions Stable medication regimen Relatively stable diet Comes to clinic for education and initiation of warfarin

31 Baseline Labs Ref. Range 12/19 INR Unknown 1.13 Prothrombi n Time Latest Ref Range: (H) Partial Thrombopla stin Time Heparin Anti Xa, Lovenox secs Latest Ref Range: secs Latest Ref Range: IU/mL 37.7 (H) 0.58 Ref. Range 12/19 WBC Latest Ref 6.3 Range: K/uL RBC Latest Ref 5.24 Range: M/uL HGB Latest Ref 14.2 (H) Range: g/dl HCT Latest Ref Range: % 43.3 (H) Platelet Count Latest Ref 291 Range: K/uL Sodium Potassium Chloride Carbon Dioxide Urea Nitrogen Creatinine Glucose Ref. Range 12/19 Latest Ref 141 Range: mmol/l Latest Ref 4.7 Range: mmol/l Latest Ref 100 Range: mmol/l Latest Ref 21 Range: mmol/l Latest Ref 17 Range: 5-17 mg/dl Latest Ref 0.5 (H) Range: mg/dl Latest Ref 67 (L) Range: mg/dl

32 Warfarin Dosing Guidelines

33 Managing in Illness Anti-Coagulation Monitoring 3/14 Warfarin Current Dose 1.5 mg M/W/F, 1 mg T/Th/S/Su Date INR: 3/13 INR Result: 4.9 INR Range: 2 to 3 # Doses missed: Clinical Info: diarrhea, decreased po intake Dose change: hold today, 1 mg tomorrow Next INR: 3/15

34 Cont d Anti-Coagulation Monitoring 3/16 Warfarin Current Dose 1 mg x1 Date INR: 3/15 INR Result: 3.2 INR Range: 2 to 3 # Doses missed: Clinical Info: HELD dose 3/14, received 1 mg 3/15 Dose change: Next INR: 3/22/2018 return to 1.5 mg M/W/F and 1 mg T/Th/S/Su as GI symptoms have improved

35 Cont d Anti-Coagulation Monitoring 3/22 Warfarin Current Dose 1.5 mg M/W/F, 1 mg T/Th/S/Su Date INR: 3/21 INR Result: 2.4 INR Range: 2 to 3 # Doses missed: Clinical Info: Dose change: Next INR: 4/5/2018

36 Case Study - DVT MM is a 5 mo month old with trisomy 21, Rastelli type A CAVC s/p repair with residual, bilateral AVVR and respiratory failure secondary to pulmonary hypertension

37 Virchow Triad Stasis: - ET tube 12/20-12/28, 2/5 - Femoral line 12/11-12/26 - PICC 12/26-2/9 Vessel Wall Injury: - Cardiac cath 11/28 and 12/11 - Open heart surgery 12/6 - Central lines Hypercoagulability: - Purulent drainage of GJ tube, on abx

38 Presentation and Plan 2/7 RLE noted to be swollen so ultrasound ordered Near occlusive thrombus within the RCIV. 2. Narrowing, incomplete color Doppler filling, and blunted waveforms within the central and mid portions of the right femoral vein suggestive of chronic non-occlusive thrombus. Femoral line 12/11-12/26 Cardiac Catheterization with RFV access 11/28 and 12/11 VTE Pathway Activated

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40 Baseline Labs Ref. Range INR Unknown 1.02 Prothrom bin Time Latest Units: secs 12.9 Urea Nitrogen Ref. Range Latest Ref Range: 2-19 mg/dl Creatinine Latest Ref Range: mg/dl HGB HCT Platelet Count Ref. Range Latest Ref 11.2 Range: g/dl Latest Ref 35.3 Range: % Latest Ref 426 (H) Range: K/uL

41 Cont d RUE noted to be swollen 2/9, US obtained Occlusive or near occlusive thrombus within the right basilic vein RUE PICC Line x44 days (pulled 2/9) Anti-Xa level on 2/8 subtherapeutic at 0.36 Failure of enoxaparin therapy??

42 Follow up 6 Week Ultrasound RLE: Decreased clot burden with improved flow in the common iliac vein RUE: all vessels patent 12 Week Ultrasound RLE: vessels patent Date 2/8 2/9 2/14 2/22 3/1 3/19 Anti-Xa Enoxaparin 7 mg BID 8 mg BID 9 mg BID 10 mg BID 10 mg BID 10 mg BID

43 Final Thoughts Enoxaparin for duration of any future central lines ASA? Post-thrombotic Syndrome

44 References Eikelboom, JW et al, New England Journal of Medicine, 2013; 369: Giglia, T, Witmer, C and Procaccini, D. Pediatric Critical Care Medicine, 2016; 17: Suppl: S77-S88 Giglia, T et al, Circulation, 2013; 128: Monagle, P et al. CHEST, 2012;141:e737s-e801s Monagle, P. CHEST. 2012;141:e737s