CICU/CCU Pathway for Management of
Acute Catheter-related Venous Thromboembolism (VTE)
- Indications for Hypercoagulability Evaluation
- Guidelines for Extremity Precautions for Thrombosis Job Aid
- Document thrombus on problem list
Assess if catheter is medically necessary
Notify Cardiac Thrombosis Team
Catheter Can Be Removed
Catheter Remains in Place
Consider anticoagulation before removal for VTE at high-risk for embolization
Low Risk of Bleeding
Active or High Risk of Bleeding
Risk benefit ratio
favors anticoagulation
favors anticoagulation
Risk outweighs anticoagulation
- Repeat US at 1 wk
- Consult Cardiac Thrombosis Team if VTE progression
Initiate Enoxaparin
Consider stopping chronic anti-platelet therapy
Repeat US in 6 wks
VTE Resolved
VTE Stable
VTE Progression
- Assess ongoing risk factors for thrombosis
- Presence of central catheter
- Active infection
- Draining chest tubes
- Strong inherited thrombophilia
Continue enoxaparin
Repeat US in 6 wks
- VTE stable or resolved
- Contact Cardiac Thrombosis Team if VTE progression
Discuss with Cardiac Thrombosis Team
Low Risk
High Risk
- Discontinue enoxaparin
- Discuss use of enoxaparin with future indwelling lines
- Discuss with Cardiac Thrombosis Team
- Consider chronic anticoagulation
- Consider enoxaparin while indwelling catheter in place
Therapeutic anticoagulation with
future mid and central line
future mid and central line
Evidence
- Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease
- Antithrombotic Therapy in Neonates and Children
- Bleeding and Thrombotic Emergencies in Pediatric Cardiac Intensive Care: Unchecked Balances
- Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Anticoagulation and Thrombolysis