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Sochet AA, Jaffray J, Branchford BR, Havlicek EE, Mosha M, Amankwah EK, Ignjatovic V, Faustino EVS, Goldenberg NA. Hospital-Acquired Venous Thromboembolism and Invasive Mechanical Ventilation: A Report From the Children's Hospital Acquired Thrombosis Consortium. Pediatr Crit Care Med 2024; 25:e82-e90. [PMID: 37882641 PMCID: PMC10843146 DOI: 10.1097/pcc.0000000000003383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
OBJECTIVES To determine if the duration of invasive mechanical ventilation (IMV) was associated with hospital-acquired venous thromboembolism (HA-VTE) among critically ill children. DESIGN A multicenter, matched case-control study as a secondary analysis of Children's Hospital Acquired Thrombosis (CHAT) Consortium registry. SETTING PICUs within U.S. CHAT Consortium participating centers. PATIENTS Children younger than 21 years old admitted to a PICU receiving IMV for greater than or equal to 1 day duration from January 2012 to March 2022 were included for study. Cases with HA-VTE were matched 1:2 to controls without HA-VTE by patient age groups: younger than 1, 1-12, and older than 12 years. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was IMV duration in days. Descriptive data included demographics, anthropometrics, HA-VTE characteristics (i.e., type, location, and timing), central venous catheterization data, thromboprophylaxis practices, and Braden Q mobility scores. Descriptive, comparative, and associative (multivariate conditional logistic regression for HA-VTE) statistics were employed. A total of 152 cases were matched to 304 controls. Cases with HA-VTE were diagnosed at a median of 7 days (interquartile range [IQR], 3-16 d) after IMV. The HA-VTE were limb deep venous thromboses in 130 of 152 (85.5%) and frequently central venous catheterization-related (111/152, 73%). Cases with HA-VTE experienced a longer length of stay (median, 34 d [IQR, 18-62 d] vs. 11.5 d [IQR, 6-21 d]; p < 0.001) and IMV duration (median, 7 d [IQR, 4-15 d] vs. 4 d [IQR, 1-7 d]; p < 0.001) as compared with controls. In a multivariate logistic model, greater IMV duration (adjusted odds ratio, 1.09; 95% CI, 1.01-1.17; p = 0.023) was independently associated with HA-VTE. CONCLUSIONS Among critically ill children undergoing IMV, HA-VTE was associated with greater IMV duration. If prospectively validated, IMV duration should be included as part of prothrombotic risk stratification and future pediatric thromboprophylaxis trials.
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Affiliation(s)
- Anthony A. Sochet
- Department of Medicine, Divisions of Critical Care Medicine , Johns Hopkins All Children’s Hospital, St. Petersburg, FL
- Institute for Clinical and Translational Research, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Julie Jaffray
- Department of Pediatrics, Division of Hematology/Oncology, Rady Children’s Hospital, San Diego, CA
| | - Brian R. Branchford
- Division of Hematology, Oncology, and Bone Marrow Transplant, Medical College of Wisconsin, Milwaukee, WI and Versiti Medical Sciences Institute, Milwaukee, WI
| | - Elizabeth E. Havlicek
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Maua Mosha
- Institute for Clinical and Translational Research, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
| | - Ernest K. Amankwah
- Institute for Clinical and Translational Research, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Vera Ignjatovic
- Institute for Clinical and Translational Research, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Neil A. Goldenberg
- Cancer and Blood Disorders Institute, Division of Hematology, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
- Institute for Clinical and Translational Research, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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Havlicek EE, Goldman ZA, Faustino EVS, Ignjatovic V, Goldenberg NA, Sochet AA. Hospital-acquired venous thromboembolism during invasive mechanical ventilation in children: a single-center, retrospective cohort study. J Thromb Haemost 2023; 21:3145-3152. [PMID: 37423387 DOI: 10.1016/j.jtha.2023.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/01/2023] [Accepted: 06/29/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Invasive mechanical ventilation (IMV) has been independently associated with hospital-acquired venous thromboembolism (HA-VTE) among critically ill children, including extremity deep venous thrombosis and pulmonary embolism. OBJECTIVES We aimed to characterize the frequency and timing of HA-VTE following IMV exposure. METHODS This was a single-center, retrospective cohort study including children aged <18 years, hospitalized in a pediatric intensive care unit, undergoing mechanical ventilation for >24 hours from October 2020 through April 2022. Encounters with an existing tracheostomy or receiving treatment for HA-VTE prior to endotracheal intubation were excluded. The primary outcomes characterized clinically-relevant HA-VTE, including timing after intubation, location, and the presence of known hypercoagulability risk factors. Secondary outcomes were IMV exposure magnitude, defined by IMV duration and ventilator parameters (ie, volumetric, barometric, and oxygenation indices). RESULTS Of 170 consecutive, eligible encounters, 18 (10.6%) experienced HA-VTE at a median of 4 days (IQR, 1.4-6.4) following endotracheal intubation. Those with HA-VTE had an increased frequency of a prior venous thromboembolism (27.8% vs 8.6%, P = .027). No differences in frequency of other HA-VTE risk factors (ie, acute immobility, hematologic malignancy, sepsis, and COVID-19-related illness), presence of a concurrent central venous catheter, or the magnitude of IMV exposure were noted. CONCLUSION Children undergoing IMV experience HA-VTE at markedly higher rates than previously estimated in the general pediatric intensive care unit population after endotracheal intubation. While prospective validation is needed, these findings are an important step toward informing the development of risk-stratified thromboprophylaxis trials in critically ill children.
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Affiliation(s)
- Elizabeth E Havlicek
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, Florida, USA; Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.
| | - Zachary A Goldman
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | | | - Vera Ignjatovic
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA; Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Neil A Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA; Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA; Department of Medicine and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anthony A Sochet
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA; Department of Medicine and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Medicine, Division of Critical Care Medicine, Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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3
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Sochet AA, Havlicek EE, Faustino EVS, Goldenberg NA. Mechanical Ventilation and Hospital-Acquired Venous Thromboembolism Among Critically Ill Children. Hosp Pediatr 2022; 12:1099-1109. [PMID: 36349533 DOI: 10.1542/hpeds.2022-006697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To estimate the occurrence of, and evaluate associations between, hospital-acquired venous thromboembolism (HA-VTE) and invasive mechanical ventilation (MV) among children hospitalized in the PICU. METHODS We performed a multicenter, retrospective cohort study comparing HA-VTE frequencies among subjects <18 years of age hospitalized in the PICU from January 2018 through December 2019 among 47 participating centers, via the Pediatric Health Information Systems registry. We excluded perinatal encounters, those with VTE present at admission, and those with observational status. The primary outcome was the proportion of HA-VTE events before hospital discharge, including extremity deep venous thrombosis, pulmonary embolism, and organ-specific deep venous thrombosis. The HA-VTE frequencies were compared using χ2 tests. The association between HA-VTE and MV was investigated via multivariable logistic regression, adjusting for previously described VTE risk factors. RESULTS Of the 205 231 PICU encounters identified for study, 70 829 (34.5%) underwent MV. The occurrence of HA-VTE was 2.2% and was greater among children who received, versus did not receive, MV (4.4% versus 1.1%, P < .001). Multivariable logistic regression revealed significant association between MV and HA-VTE (odds ratio 2.51, 95% confidence interval 2.33-2.69; P < .001). CONCLUSIONS In this multicenter, retrospective, registry-based cohort study, HA-VTE were diagnosed in 2.2% of critically-ill children, and after adjustment for central venous catheterization, MV independently increased the risk of HA-VTE 2.5-fold. These findings warrant prospective validation to inform the design of future risk-stratified clinical trials of thromboprophylaxis in critically-ill children.
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Affiliation(s)
- Anthony Alexander Sochet
- Divisions of Critical Care Medicine.,Department of Pediatrics, University of South Florida College of Medicine, Tampa, Florida.,Departments of Anesthesiology.,Critical Care Medicine, Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | | | | | - Neil Andrew Goldenberg
- Hematology, Department of Medicine, Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Critical Care Medicine, Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Departments of Medicine.,Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Risk factors for hospital acquired venous thromboembolism in congenital heart disease patients: A report from the children's hospital acquired thrombosis (CHAT) consortium. Thromb Res 2022; 220:116-120. [DOI: 10.1016/j.thromres.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 10/10/2022] [Accepted: 10/18/2022] [Indexed: 11/17/2022]
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Wang YJ, Lei L, Huang Y. Factors associated with venous thromboembolism in the paediatric intensive care unit: A systematic review and meta‐analysis. Nurs Crit Care 2022. [DOI: 10.1111/nicc.12813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Ya Jing Wang
- West China School of Nursing, Sichuan University/Nursing Department, West China Second University Hospital Sichuan University Chengdu China
- Nursing Department West China Second University Hospital, Sichuan University Chengdu China
| | - Lei Lei
- Nursing Department West China Second University Hospital, Sichuan University Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education Chengdu China
| | - Yan Huang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education Chengdu China
- Department of pediatric Intensive Care Unit, Nursing Department, West China second University Sichuan University Chengdu China
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Sochet AA, Morrison JM, Jaffray J, Godiwala N, Wilson HP, Thornburg CD, Bhat RV, Zia A, Lawrence C, Kudchadkar SR, Hamblin F, Russell CJ, Streiff MB, Spyropoulos AC, Amankwah EK, Goldenberg NA. Enoxaparin Thromboprophylaxis in Children Hospitalized for COVID-19: A Phase 2 Trial. Pediatrics 2022; 150:e2022056726. [PMID: 35484817 DOI: 10.1542/peds.2022-056726] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Evidence regarding the safety and efficacy of anticoagulant thromboprophylaxis among pediatric patients hospitalized for coronavirus disease 2019 (COVID-19) is limited. We sought to evaluate safety, dose-finding, and preliminary efficacy of twice-daily enoxaparin as primary thromboprophylaxis among children hospitalized for symptomatic COVID-19, including primary respiratory infection and multisystem inflammatory syndrome in children (MISC). METHODS We performed a phase 2, multicenter, prospective, open-label, single-arm clinical trial of twice-daily enoxaparin (initial dose: 0.5mg/kg per dose; max: 60mg; target anti-Xa activity: 0.20-0.49IU/mL) as primary thromboprophylaxis for children <18 years of age hospitalized for symptomatic COVID-19. Study endpoints included: cumulative incidence of International Society of Thrombosis and Haemostasis-defined clinically relevant bleeding; enoxaparin dose-requirements; and cumulative incidence of venous thromboembolism within 30-days of hospital discharge. Descriptive statistics summarized endpoint estimates that were further evaluated by participant age (±12 years) and clinical presentation. RESULTS Forty children were enrolled and 38 met analyses criteria. None experienced clinically relevant bleeding. Median (interquartile range) dose to achieve target anti-Xa levels was 0.5 mg/kg (0.48-0.54). Dose-requirement did not differ by age (0.5 [0.46-0.52] mg/kg for age ≥12 years versus 0.52 [0.49-0.55] mg/kg for age <12 years, P = .51) but was greater for participants with MISC (0.52 [0.5-0.61] mg/kg) as compared with primary COVID-19 (0.48 [0.39-0.51] mg/kg, P = .010). Two children (5.3%) developed central-venous catheter-related venous thromboembolism. No serious adverse events were related to trial intervention. CONCLUSIONS Among children hospitalized for COVID-19, thromboprophylaxis with twice-daily enoxaparin appears safe and warrants further investigation to assess efficacy.
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Affiliation(s)
| | | | - Julie Jaffray
- Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Nihal Godiwala
- Department of Pediatrics, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Hope P Wilson
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham, Alabama
| | - Courtney D Thornburg
- Department of Pediatrics, University of California San Diego, La Jolla, California Division of Hematology and Oncology, Rady Children's Hospital San Diego, San Diego, California
| | - Rukhmi V Bhat
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ayesha Zia
- Department of Pediatrics, The University of Texas Southwestern, Dallas, Texas
| | | | - Sapna R Kudchadkar
- Critical Care Medicine
- Pediatrics
- Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Christopher J Russell
- Department of Pediatrics, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Alex C Spyropoulos
- Department of Medicine, Zucker School of Medicine at Hofstra and Northwell and Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Ernest K Amankwah
- Departments of Anesthesia
- Pediatrics
- Oncology, Johns Hopkins All Children's Institute for Clinical and Translational Research
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Jaffray J, Mahajerin A, Branchford B, Nguyen ATH, Faustino EVS, Silvey M, Croteau SE, Fargo JH, Cooper JD, Bakeer N, Zakai NA, Stillings A, Krava E, Amankwah EK, Young G, Goldenberg NA. A New Risk Assessment Model for Hospital-Acquired Venous Thromboembolism in Critically Ill Children: A Report From the Children's Hospital-Acquired Thrombosis Consortium. Pediatr Crit Care Med 2022; 23:e1-e9. [PMID: 34406168 PMCID: PMC8738123 DOI: 10.1097/pcc.0000000000002826] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To create a risk model for hospital-acquired venous thromboembolism in critically ill children upon admission to an ICU. DESIGN Case-control study. SETTING ICUs from eight children's hospitals throughout the United States. SUBJECTS Critically ill children with hospital-acquired venous thromboembolism (cases) 0-21 years old and similar children without hospital-acquired venous thromboembolism (controls) from January 2012 to December 2016. Children with a recent cardiac surgery, asymptomatic venous thromboembolism, or a venous thromboembolism diagnosed before ICU admission were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The multi-institutional Children's Hospital-Acquired Thrombosis registry was used to identify cases and controls. Multivariable logistic regression was used to determine the association between hospital-acquired venous thromboembolism and putative risk factors present at or within 24 hours of ICU admission to develop the final model. A total of 548 hospital-acquired venous thromboembolism cases (median age, 0.8 yr; interquartile range, 0.1-10.2) and 187 controls (median age, 2.4 yr; interquartile range, 0.2-8.3) were analyzed. In the multivariable model, recent central venous catheter placement (odds ratio, 4.4; 95% CI, 2.7-7.1), immobility (odds ratio 3.6, 95% CI, 2.1-6.2), congenital heart disease (odds ratio 2.9, 95% CI, 1.7-4.7), length of hospital stay prior to ICU admission greater than or equal to 3 days (odds ratio, 2.5; 95% CI, 1.1-5.6), and history of autoimmune/inflammatory condition or current infection (odds ratio, 2.1; 95% CI, 1.2-3.4) were each independently associated with hospital-acquired venous thromboembolism. The risk model had an area under the receiver operating characteristic curve of 0.79 (95% CI, 0.73-0.84). CONCLUSIONS Using the multicenter Children's Hospital-Acquired Thrombosis registry, we identified five independent risk factors for hospital-acquired venous thromboembolism in critically ill children, deriving a new hospital-acquired venous thromboembolism risk assessment model. A prospective validation study is underway to define a high-risk group for risk-stratified interventional trials investigating the efficacy and safety of prophylactic anticoagulation in critically ill children.
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Affiliation(s)
- Julie Jaffray
- Children’s Hospital Los Angeles, Los Angeles, CA, USA
- University of Southern California Keck School of Medicine, Department of Pediatrics, Los Angeles, CA, USA
| | | | - Brian Branchford
- Children’s Hospital Colorado, Aurora, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
- Versiti Blood Research Institute, Milwaukee, WI, USA
| | - Anh Thy H. Nguyen
- Data Coordinating Center, Johns Hopkins All Children’s Institute for Clinical and Translational Research, St. Petersburg, FL, USA
| | | | | | - Stacy E. Croteau
- Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | | | - Nihal Bakeer
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN, USA
| | - Neil A. Zakai
- Larner College of Medicine at the University of Vermont, Department of Medicine and Department of Pathology & Laboratory Medicine, Burlington, VT, USA
| | - Amy Stillings
- Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Emily Krava
- Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Ernest K. Amankwah
- Data Coordinating Center, Johns Hopkins All Children’s Institute for Clinical and Translational Research, St. Petersburg, FL, USA
- Johns Hopkins University School of Medicine, Departments of Oncology and Pediatrics, Baltimore, MD, USA
| | - Guy Young
- Children’s Hospital Los Angeles, Los Angeles, CA, USA
- University of Southern California Keck School of Medicine, Department of Pediatrics, Los Angeles, CA, USA
| | - Neil A. Goldenberg
- Data Coordinating Center, Johns Hopkins All Children’s Institute for Clinical and Translational Research, St. Petersburg, FL, USA
- Johns Hopkins University School of Medicine, Departments of Pediatrics and Medicine, Baltimore, MD, USA
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Sochet AA, Kiskaddon A, Betensky M, Goldenberg N. Venous Thromboembolism among Critically Ill Children: A Narrative Review. Semin Thromb Hemost 2021; 47:631-642. [PMID: 34058768 DOI: 10.1055/s-0041-1722847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Venous thromboembolism (VTE) is a leading cause of morbidity and mortality among hospitalized patients, including children. In recent years, it has become clear that hospitalization and critical illness bestow an increased VTE risk in pediatrics and relate to mortality and life-limiting comorbidities. For critically ill children, reported rates of VTE vary by study sampling techniques, presence of inherited or acquired thrombophilia, acute and chronic immobility, underlying illness prompting hospitalization, and clinical factors related to illness severity such as central venous catheterization, length of stay, mechanical ventilation, and patient age. Accordingly, critically ill children with new signs of venous congestion, acute inflammation, or unexplained acute organ dysfunction should be routinely evaluated for VTE. This narrative review summarizes recent and historical literature regarding risk factors, prevention, presentation, treatment, and outcomes of VTE in critically ill children. In addition, we identify knowledge gaps and priorities for future collaborative research on this vital condition. Special attention is given to the clinical trial opportunities, challenges, and ongoing efforts in thromboprophylaxis in critically ill children, including those hospitalized for disease related to novel coronavirus (COVID-19) and multisystem inflammatory disease in children.
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Affiliation(s)
- Anthony A Sochet
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Pediatric Critical Care Medicine, Department of Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Amy Kiskaddon
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Marisol Betensky
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Thrombosis Program, Johns Hopkins All Children's Cancer and Blood Disorder Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Neil Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Thrombosis Program, Johns Hopkins All Children's Cancer and Blood Disorder Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Morrison JM, Betensky M, Kiskaddon AL, Goldenberg NA. Venous Thromboembolism among Noncritically Ill Hospitalized Children: Key Considerations for the Pediatric Hospital Medicine Specialist. Semin Thromb Hemost 2021; 48:434-445. [PMID: 33962474 DOI: 10.1055/s-0041-1729170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Venous thromboembolism (VTE) is a leading cause of morbidity and preventable harm among noncritically ill hospitalized children. Several clinical factors relevant to the noncritically ill hospitalized child significantly increase the risk of VTE including the presence of central venous catheters, systemic inflammation, and prolonged immobilization. Although risk mitigation strategies have been described, the diagnosis, treatment, and prevention of VTE require standardization of institutional practices combined with multidisciplinary collaboration among pediatric hospitalists, hematologists, and other care providers. In this narrative review, we summarize the epidemiology of VTE, risk models identifying high-risk conditions associated with VTE, and prevention and treatment strategies. We further describe successful quality improvement efforts implementing institutional VTE risk stratification and thromboprophylaxis procedures. Finally, we highlight unique challenges facing pediatric hospital medicine specialists in the era of the COVID-19 pandemic, including caring for adults admitted to pediatric hospital units, and describe future research opportunities for VTE in the noncritically ill hospitalized child.
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Affiliation(s)
- John M Morrison
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Pediatric Hospital Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Marisol Betensky
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Pediatric Hematology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Amy L Kiskaddon
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Neil A Goldenberg
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Pediatric Hematology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
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Jaffray J, Branchford B, Goldenberg N, Malvar J, Croteau SE, Silvey M, Fargo JH, Cooper JD, Bakeer N, Sposto R, Ji L, Zakai NA, Faustino EVS, Stillings A, Krava E, Young G, Mahajerin A. Development of a Risk Model for Pediatric Hospital-Acquired Thrombosis: A Report from the Children's Hospital-Acquired Thrombosis Consortium. J Pediatr 2021; 228:252-259.e1. [PMID: 32920105 PMCID: PMC7752847 DOI: 10.1016/j.jpeds.2020.09.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To identify pertinent clinical variables discernible on the day of hospital admission that can be used to assess risk for hospital-acquired venous thromboembolism (HA-VTE) in children. STUDY DESIGN The Children's Hospital-Acquired Thrombosis Registry is a multi-institutional registry for all hospitalized participants aged 0-21 years diagnosed with a HA-VTE and non-VTE controls. A risk assessment model (RAM) for the development of HA-VTE using demographic and clinical VTE risk factors present at hospital admission was derived using weighted logistic regression and the least absolute shrinkage and selection (Lasso) procedure. The models were internally validated using 5-fold cross-validation. Discrimination and calibration were assessed using area under the receiver operating characteristic curve and Hosmer-Lemeshow goodness of fit, respectively. RESULTS Clinical data from 728 cases with HA-VTE and 839 non-VTE controls, admitted between January 2012 and December 2016, were abstracted. Statistically significant RAM elements included age <1 year and 10-22 years, cancer, congenital heart disease, other high-risk conditions (inflammatory/autoimmune disease, blood-related disorder, protein-losing state, total parental nutrition dependence, thrombophilia/personal history of VTE), recent hospitalization, immobility, platelet count >350 K/μL, central venous catheter, recent surgery, steroids, and mechanical ventilation. The area under the receiver operating characteristic curve was 0.78 (95% CI 0.76-0.80). CONCLUSIONS Once externally validated, this RAM will identify those who are at low-risk as well as the greatest-risk groups of hospitalized children for investigation of prophylactic strategies in future clinical trials.
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Affiliation(s)
- Julie Jaffray
- Children's Hospital Los Angeles, Los Angeles, CA; University of Southern California Keck School of Medicine, Los Angeles, CA.
| | - Brian Branchford
- Children's Hospital Colorado, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| | - Neil Goldenberg
- Johns Hopkins All Children's Hospital, Baltimore, MD; Department of Pediatrics and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Stacy E Croteau
- Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | | | | | | | - Nihal Bakeer
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN
| | - Richard Sposto
- University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Lingyun Ji
- University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Neil A Zakai
- Department of Medicine, Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont Burlington, Burlington, VT
| | | | | | - Emily Krava
- Children's Hospital Los Angeles, Los Angeles, CA
| | - Guy Young
- Children's Hospital Los Angeles, Los Angeles, CA; University of Southern California Keck School of Medicine, Los Angeles, CA
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Kaipa S, Mastropietro CW, Bhai H, Lutfi R, Friedman ML, Yabrodi M. Upper body peripherally inserted central catheter in pediatric single ventricle patients. World J Cardiol 2020; 12:484-491. [PMID: 33173567 PMCID: PMC7596420 DOI: 10.4330/wjc.v12.i10.484] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/19/2020] [Accepted: 08/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There is risk of stenosis and thrombosis of the superior vena cava after upper extremity central catheter replacement. This complication is more serious among patients with single ventricle physiology, as it might preclude them from undergoing further life-sustaining palliative surgery.
AIM To describe complications associated with the use of upper extremity percutaneous intravenous central catheters (PICCs) in children with single ventricle physiology.
METHODS A single institution retrospective review of univentricular patients who underwent superior cavopulmonary anastomoses as their stage 2 palliation procedure from January 2014 until December 2018 and had upper body PICCs placed at any point prior to this procedure. Clinical data including ultrasonography, cardiac catheterization, echocardiogram reports and patient notes were used to determine the presence of thrombus or stenosis of the upper extremity and cervical vessels. Data regarding the presence and duration of upper extremity PICCs and upper extremity central venous catheter (CVC), and use of anticoagulation were recorded.
RESULTS Seventy-six patients underwent superior cavopulmonary anastomoses, of which 56 (73%) had an upper extremity PICC at some point prior to this procedure. Median duration of PICC usage was 24 d (25%, 75%: 12, 39). Seventeen patients (30%) with PICCs also had internal jugular or subclavian central venous catheters (CVCs) in place at some point prior to their superior cavopulmonary anastomoses, median duration 10 d (25%, 75%: 8, 14). Thrombus was detected in association with 2 of the 56 PICCs (4%) and 3 of the 17 CVCs (18%). All five patients were placed on therapeutic dose of low molecular weight heparin at the time of thrombus detection and subsequent cardiac catheterization demonstrated resolution in three of the five patients. No patients developed clinically significant venous stenosis.
CONCLUSION Use of upper extremity PICCs in patients with single ventricle physiology prior to super cavopulmonary anastomosis is associated with a low rate of catheter-associated thrombosis.
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Affiliation(s)
- Santosh Kaipa
- Department of Pediatrics, Division of Pediatric Critical Care, Indiana University, Riley Hospital for Children, Indianapolis, IN 46303, United States
| | - Christopher W Mastropietro
- Department of Pediatrics, Division of Pediatric Critical Care, Indiana University, Riley Hospital for Children, Indianapolis, IN 46303, United States
| | - Hamza Bhai
- Department of Pediatrics, Division of Pediatric Critical Care, Indiana University, Riley Hospital for Children, Indianapolis, IN 46303, United States
| | - Riad Lutfi
- Department of Pediatrics, Division of Pediatric Critical Care, Indiana University, Riley Hospital for Children, Indianapolis, IN 46303, United States
| | - Matthew L Friedman
- Department of Pediatrics, Division of Pediatric Critical Care, Indiana University, Riley Hospital for Children, Indianapolis, IN 46303, United States
| | - Mouhammad Yabrodi
- Department of Pediatrics, Division of Pediatric Critical Care, Indiana University, Riley Hospital for Children, Indianapolis, IN 46303, United States
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12
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Hosokawa T, Shibuki S, Tanami Y, Sato Y, Ko Y, Nomura K, Oguma E. Extracardiac Complications in Intensive Care Units after Surgical Repair for Congenital Heart Disease: Imaging Review with a Focus on Ultrasound and Radiography. J Pediatr Intensive Care 2020; 10:85-105. [PMID: 33884209 DOI: 10.1055/s-0040-1715483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/24/2020] [Indexed: 12/24/2022] Open
Abstract
Pediatric patients show various extracardiac complications after cardiovascular surgery, and radiography and ultrasound are routinely performed in the intensive care unit to detect and evaluate these complications. This review presents images of these complications, sonographic approach, and timing of occurrence that are categorized based on their extracardiac locations and include complications pertaining to the central nervous system, mediastinum, thorax and lung parenchyma, diaphragm, liver and biliary system, and kidney along with pleural effusion and iatrogenic complications. This pictorial review will make it easier for medical doctors in intensive care units to identify and manage various extracardiac complications in pediatric patients after cardiovascular surgery.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Saki Shibuki
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yoshihiro Ko
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Koji Nomura
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
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13
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Hospital-Associated Venous Thromboembolism in a Pediatric Cardiac ICU: A Multivariable Predictive Algorithm to Identify Children at High Risk. Pediatr Crit Care Med 2020; 21:e362-e368. [PMID: 32343105 DOI: 10.1097/pcc.0000000000002293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Critically ill children with cardiac disease are at significant risk for hospital-associated venous thromboembolism, which is associated with increased morbidity, hospital length of stay, and cost. Currently, there are no widely accepted guidelines for prevention of hospital-associated venous thromboembolism in pediatrics. We aimed to develop a predictive algorithm for identifying critically ill children with cardiac disease who are at increased risk for hospital-associated venous thromboembolism as a first step to reducing hospital-associated venous thromboembolism in this population. DESIGN This is a prospective observational single-center study. SETTING Tertiary care referral children's hospital cardiac ICU. PATIENTS Children less than or equal to18 years old admitted to the cardiac ICU who developed a hospital-associated venous thromboembolism from December 2013 to June 2017 were included. Odds ratios and 95% CIs are reported for multivariable predictors. MEASUREMENTS AND MAIN RESULTS A total of 2,204 separate cardiac ICU encounters were evaluated with 56 hospital-associated venous thromboembolisms identified in 52 unique patients, yielding an overall prevalence of 25 hospital-associated venous thromboembolism per 1,000 cardiac ICU encounters. We were able to create a predictive algorithm with good internal validity that performs well at predicting hospital-associated venous thromboembolism. The presence of a central venous catheter (odds ratio, 4.76; 95% CI, 2.0-11.1), sepsis (odds ratio, 3.5; 95% CI, 1.5-8.0), single ventricle disease (odds ratio, 2.2; 95% CI, 1.2-3.9), and extracorporeal membrane oxygenation support (odds ratio, 2.7; 95% CI, 1.2-5.7) were independent risk factors for hospital-associated venous thromboembolism. Encounters with hospital-associated venous thromboembolism were associated with a higher rate of stroke (17% vs 1.2%; p < 0.001). CONCLUSIONS We developed a multivariable predictive algorithm to help identify children who may be at high risk of hospital-associated venous thromboembolism in the pediatric cardiac ICU.
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14
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Jaffray J, Goldenberg N. Current approaches in the treatment of catheter-related deep venous thrombosis in children. Expert Rev Hematol 2020; 13:607-617. [DOI: 10.1080/17474086.2020.1756260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Julie Jaffray
- Department of Pediatrics, Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Neil Goldenberg
- Departments of Pediatrics and Medicine, Divisions of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins All Children’s Cancer and Blood Disorders Institute, St. Petersburg, FL, USA
- Johns Hopkins All Children’s Institute for Clinical and Translational Research, St. Petersburg, FL, USA
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15
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Donahue BS. Red Cell Transfusion and Thrombotic Risk in Children. Pediatrics 2020; 145:peds.2019-3955. [PMID: 32198294 DOI: 10.1542/peds.2019-3955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2019] [Indexed: 01/28/2023] Open
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16
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Steen EH, Lasa JJ, Nguyen TC, Keswani SG, Checchia PA, Anders MM. Central Venous Catheter-Related Deep Vein Thrombosis in the Pediatric Cardiac Intensive Care Unit. J Surg Res 2019; 241:149-159. [PMID: 31026793 DOI: 10.1016/j.jss.2019.03.052] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/08/2019] [Accepted: 03/22/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Central venous catheter (CVC) use is common in the management of critically ill children, especially those with congenital heart disease. CVCs are known to augment the risk of deep vein thrombosis (DVT), but data on CVC-associated DVTs in the pediatric cardiac intensive care unit (CICU) are limited. In this study, we aim to identify the incidence of and risk factors for CVC-related DVT in this high-risk population, as its complications are highly morbid. MATERIALS AND METHODS The PC4 database and a radiologic imaging database were retrospectively reviewed for the demographics and outcomes of patients admitted to the Texas Children's Hospital CICU requiring CVC placement, as well as the incidence of DVT and its complications. RESULTS Between January 2017 and December 2017, 1215 central lines were placed over 851 admissions. DVT was diagnosed in 8% of admissions with a CVC, 29% of which demonstrated thrombus in the inferior vena cava. The risk factors significantly associated with DVT included the presence of >1 line, higher total line hours, longer intubation times, and extended CICU stay. A diagnosis of low cardiac output syndrome, sepsis, central line-associated bloodstream infection, and cardiac catheterization were also significant risk factors. Interestingly, cardiac surgery with cardiopulmonary bypass appeared to be protective of clot development. DVT was a highly significant risk factor for mortality in these patients. CONCLUSIONS CVC-related DVTs in critically ill children with congenital heart disease are associated with higher risks of morbidity and mortality, highlighting the need for well-designed studies to determine the best preventative and treatment strategies and to establish guidelines for appropriate monitoring and follow-up of these patients.
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Affiliation(s)
- Emily H Steen
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Laboratory for Regenerative Tissue Repair, Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Javier J Lasa
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Trung C Nguyen
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Sundeep G Keswani
- Laboratory for Regenerative Tissue Repair, Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Paul A Checchia
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Marc M Anders
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
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17
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Mahajerin A, Betensky M, Goldenberg NA. Thrombosis in Children: Approach to Anatomic Risks, Thrombophilia, Prevention, and Treatment. Hematol Oncol Clin North Am 2019; 33:439-453. [PMID: 31030812 DOI: 10.1016/j.hoc.2019.01.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Pediatric venous thromboembolism (VTE) is increasing in incidence but minimal data exist for best practices regarding therapy, use of thrombophilia testing, and management of long-term complications. Classification schema use anatomic location and presence of clinical or thrombophilic inciting factors. There are a small number of risk-assessment and risk-modeling systems for incident VTE, but all suffer from low numbers, single-institution design, and lack of prospective validation. Acute treatment is limited to heparin products and thrombolysis may be indicated in specific situations. In addition, chronic postthrombotic comorbidities are expected to increase in incidence and lack evidence-based treatment paradigms.
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Affiliation(s)
- Arash Mahajerin
- Division of Hematology, 1201 West La Veta Avenue, Orange, CA 92868, USA.
| | - Marisol Betensky
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Pediatric Thrombosis Program, Johns Hopkins All Children's Cancer and Blood Disorder Institute, Johns Hopkins Medicine, 600 5th Street South, 4th Floor, St Petersburg, FL 33701, USA
| | - Neil A Goldenberg
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Medicine, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Pediatric Thrombosis Program, Johns Hopkins All Children's Hospital, Johns Hopkins All Children's Cancer and Blood Disorder Institute, Johns Hopkins Medicine, 600 5th Street South, 3rd Floor, St Petersburg, FL 33701, USA; Johns Hopkins Children's Center, Baltimore, MD, USA
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18
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Newall F, Branchford B, Male C. Anticoagulant prophylaxis and therapy in children: current challenges and emerging issues. J Thromb Haemost 2018; 16:196-208. [PMID: 29316202 DOI: 10.1111/jth.13913] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This review is aimed at describing the unique challenges of anticoagulant prophylaxis and treatment in children, and highlighting areas for research for improving clinical outcomes of children with thromboembolic disease. The evidence presented demonstrates the challenges of advancing the evidence base informing optimal management of thromboembolic disease in children. Recent observational studies have identified risk factors for venous thromboembolism in children, but there are few interventional studies assessing the benefit-risk balance of using thromboprophylaxis in risk-stratified clinical subgroups. A risk level-based framework is proposed for administering mechanical and pharmacological thromboprophylaxis. More research is required to refine the assignment of risk levels. The anticoagulants currently used predominantly in children are unfractionated heparin, low molecular weight heparin, and vitamin K antagonists. There is a paucity of robust evidence on the age-specific pharmacology of these agents, and their efficacy and safety for prevention and treatment of thrombosis in children. The available literature is heterogeneous, reflecting age-specific differences, and the various clinical settings for anticoagulation in children. Monitoring assays and target ranges are not well established. Nevertheless, weight-based dosing appears to achieve acceptable outcomes in most indications. Given the limitations of the classical anticoagulants for children, there is great interest in the direct oral anticoagulants (DOACs), whose properties appear to be particularly suitable for children. All DOACs currently approved for adults have Pediatric Investigation Plans ongoing or planned. These are generating age-specific formulations and systematic dosing information. The ongoing pediatric studies still have to establish whether DOACs have a positive benefit-risk balance in the various pediatric indications and age groups.
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Affiliation(s)
- F Newall
- Clinical Haematology & Nursing Research, Royal Children's Hospital, Haematology Research Group, Murdoch Childrens Research Institute and Departments of Paediatrics and Nursing, The University of Melbourne, Melbourne, Australia
| | - B Branchford
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplant and the Hemophilia and Thrombosis Center, School of Medicine and Center for Cancer and Blood Disorders, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - C Male
- Haemostasis and Thrombosis Unit, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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