Clinical features and outcome of pulmonary embolism in children

Risk factors for suspected pulmonary embolism in children: Complication of Mycoplasma pneumoniae pneumonia

PURPOSE

Pulmonary embolism (PE) is not a rare complication of Mycoplasma pneumoniae pneumonia (MPP) in children. We sought to determine the incidence of PE in children with MPP who underwent clinically indicated CT pulmonary angiography (CTPA) and to evaluate the risk factors for PE.

METHODS

All 106 children with MPP who were clinically suspected of having PE and who underwent CTPA were retrospectively enrolled from June 2018 to December 2021. The clinical features, laboratory data, and radiological parameters were recorded (e.g., lung consolidation involved and the Qanadli score). A Cox proportional hazards model and area under the receiver operating characteristic (ROC) curve were used to evaluate the risk factors and prognostic discriminatory capacity for PE.

RESULTS

PE was detected in 26 of 106 (24.5 %) children (mean age, 6.2 years ± 3.3 years; 53 boys). Sixteen of the 26 (61.5 %) children with PE were boys. The mean age of the children with PE was 8.1 ± 2.9 years, and the mean Qanadli score was 15.3 ± 10.2. Children with PE had higher D-dimer levels (9.3 ± 7.1 mg/Lvs. 3.6 ± 3.8 mg/L) and a greater frequency of lung lobe consolidation (25 (96.2 %) vs. 64 (80.0 %)) (all P < 0.05). For children with MPP, age (hazard ratio (HR) = 1.96 (95 % CI1.04, 3.71; P = 0.037), D-dimer level (HR = 1.52, 95 % CI: 1.03, 2.24; P = 0.029), and bilateral lung consolidation (HR = 2.41, 95 % CI: 1.03, 5.58; P = 0.043) were found to be independent predictors of PE.

CONCLUSION

Clinical and CT radiological predictors could be used to predict PE in children with MPP. The use of risk factor assessment as a tool has the potential to guide more appropriate use of CTPA in children.

Uncovering Risk Factors and Outcomes of Pulmonary Embolism in a Nationwide Cohort of Hospitalized Children

PURPOSE

The incidence of pulmonary embolism (PE) in hospitalized children has increased in recent years. This study sought to characterize factors and outcomes associated with PE using a national pediatric cohort.

METHODS

The Nationwide Readmissions Database was queried (2016-2018) for patients (<18 years) with a diagnosis of PE. Index and prior hospitalizations (PHs) within 1 year were analyzed. A binary logistic regression utilizing 37 covariates (demographics, procedures, comorbidities, etc.) was constructed to examine a primary outcome of in-hospital mortality.

RESULTS

3440 patients were identified (57% female) with the majority >12 years old (77%). One-third had a known deep vein thrombosis (69% lower and 31% upper extremity). Nineteen percent underwent central venous catheter (CVC) placement. Twenty-one percent had a PH within 1 year. Nine percent underwent an operation with the majority being cardiothoracic (5%). Overall mortality was 5%. Neurocranial surgery, cardiothoracic surgery, and CVC placement were associated with the highest odds of inpatient mortality after logistic regression.

CONCLUSION

Pediatric patients with PE have a high rate of PHs, CVC placement, and inpatient operations, which may be associated with higher mortality. This information can be utilized to improve screening measures and clinical suspicion for PE in hospitalized children.

Pediatric pulmonary thromboembolism: a 3-year Canadian Pediatric Surveillance Program study

BACKGROUND

Pediatric pulmonary embolism (PE) is a rare event associated with significant morbidity and mortality. Awareness of clinical presentation and practices unique to children may aid clinicians in prompt identification and treatment.

OBJECTIVES

To describe the incidence, risk factors, clinical presentation, diagnostic and therapeutic practices, and short-term outcomes of pediatric PE.

METHODS

We conducted a 3-year national surveillance study through the Canadian Pediatric Surveillance Program. Over 2800 pediatric specialists and subspecialists were contacted monthly from 2020 to 2022 and requested to report all new cases of PE in patients up to 18 years of age. Case-specific data were obtained through voluntary completion of a detailed questionnaire.

RESULTS

Fifty-eight cases (78% female, n = 45) were reported (2.4 cases per million children), with rates highest in adolescents 15 to 18 years (6.6 cases per million). Detailed information, available for 31 (53%) cases, documented at least 1 risk factor in 28 (90%) cases; 24 (77%) patients presented with 2 or more symptoms. Computed tomography pulmonary angiography was used for diagnostic confirmation in 25 (81%) cases. Anticoagulation was initiated in 24 (77%) of 31 cases; fewer than 5 patients underwent thrombolysis or surgical interventions. Of 28 patients who received therapeutic interventions, 8 (29%) experienced treatment-related complications. Fewer than 5 mortalities were reported.

CONCLUSION

Pediatric PE is a rare event, with female adolescents at the highest risk. Although the presentation is often nonspecific, clinicians should maintain a high index of suspicion, particularly in patients with risk factors and when other diagnoses that may explain symptoms have been excluded.

Long-term outcomes of pulmonary embolism in children and adolescents

ABSTRACT

Knowledge regarding the long-term consequences of pulmonary embolism (PE) in children is limited. This cohort study describes the long-term outcomes of PE in children who were followed-up at a single-center institution using a local protocol that included clinical evaluation, chest imaging, echocardiography, pulmonary function tests, and cardiopulmonary exercise tests at follow-up, starting 3 to 6 months after acute PE. Children objectively diagnosed with PE at age 0 to 18 years, who had ≥6 months of follow-up were included. Study outcomes consisted of PE resolution, PE recurrence, death, and functional outcomes (dyspnea, impaired pulmonary or cardiac function, impaired aerobic capacity, and post-PE syndrome). The frequency of outcomes was compared between patients with/without underlying conditions. In total, 150 patients were included; median age at PE was 16 years (25th-75th percentile, 14-17 years); 61% had underlying conditions. PE did not resolve in 29%, recurrence happened in 9%, and death in 5%. One-third of patients had at least 1 documented abnormal functional finding at follow-up (ventilatory impairments, 31%; impaired aerobic capacity, 31%; dyspnea, 26%; and abnormal diffusing capacity of the lungs to carbon monoxide, 22%). Most abnormalities were transient. When alternative explanations for the impairments were considered, the frequency of post-PE syndrome was lower, ranging between 0.7% and 8.5%. Patients with underlying conditions had significantly higher recurrence, more pulmonary function and ventilatory impairments, and poorer exercise capacity. Exercise intolerance was, in turn, most frequently because of deconditioning than to respiratory or cardiac limitation, highlighting the importance of physical activity promotion in children with PE.

Case Report: In situ pulmonary artery thrombosis in a 12-year-old girl classified as systemic lupus erythematosus

In situ pulmonary artery thrombosis (ISPAT) is a relatively rare but potentially life-threatening complication of systemic lupus erythematosus (SLE) in children. We report the case of a 12-year-old girl who presented with fever, chest pain, and dyspnea. Immune thrombocytopenia was identified due to purpura and menorrhagia 3 months before presentation with a lowest platelet count of 12 × 109/L. The sudden onset of fever, chest pain, and dyspnea were misdiagnosed as hyperinflammatory responses caused by pneumonia; these symptoms ameliorated with glucocorticoid and antibiotic treatment. The reappearance of symptoms after dose reduction of glucocorticoids and the observation of bloody bronchoalveolar lavage fluid necessitated further evaluation. Pulmonary artery thrombosis/embolism was identified using computed tomography pulmonary angiography and high D-dimer quantitative level of 4,118 μg/L (normal <252 μg/L). Ultrasonography of the deep and superficial veins of both lower limbs and renal veins revealed no thrombosis, suggesting the diagnosis of ISPAT. Further etiological evaluation revealed positive antinuclear antibodies, lupus anticoagulant, and anti-SSA antibodies, confirming SLE. Repeated normal urine analysis indicated that lupus nephritis was unlikely. Further, the negative anticardiolipin and anti-β2 glycoprotein antibodies and temporary positive lupus anticoagulant suggested that antiphospholipid syndrome was unlikely. The patient received anticoagulants, glucocorticoids, hydroxychloroquine, and mycophenolate therapy. Her symptoms gradually improved, and she was discharged. At the 1-month follow-up, the thrombosis had resolved. During the 1-year follow-up, her condition remained well without SLE relapse. Our experience with this case emphasizes searching for SLE in the case of ISPAT and pulmonary hemorrhages. ISPAT can occur in children with SLE and may be caused by hyperinflammatory response during SLE flare.

Clinical prediction tool to identify children at risk of pulmonary embolism

INTRODUCTION

The diagnosis of pediatric pulmonary embolism (PE) is often delayed due to non-specific symptoms, and clinical prediction tools designed for adults are unsuitable for children. This study aimed to create a PE predictive model and to evaluate the reported tools in the Thai pediatric population.

MATERIALS AND METHODS

A multi-center retrospective study from 4 university hospitals included children ≤18 years of age undergoing computed tomography pulmonary angiogram from 2000 to 2020 with the suspicion of PE. Patients' clinical presentations and risk factors of venous thromboembolism (VTE) were compared between the PE-positive and PE-negative groups. Significant risk factors from univariate and multivariate logistic regression were included to create a clinical prediction tool. The performance of the model was demonstrated by sensitivity, specificity, area under the curve (AUC), Hosmer Lemeshow test, ratio of observed and expected outcomes and bootstrapping.

RESULTS

Of the 104 patients included, 43 (41.3 %) were grouped as PE-positive and 61 (58.7 %) as PE-negative. Five parameters, including congenital heart disease/pulmonary surgery, known thrombophilia, previous VTE, nephrotic syndrome and chest pain showed significant differences between the two groups. Score ≥ 2 yielded a 74.4 % sensitivity and a 75.4 % specificity with an AUC of the model of 0.809. The model performance and validation results were within satisfactory ranges.

CONCLUSION

The study created a clinical prediction tool indicating the likelihood of PE among Thai children. A score ≥2 was suggestive of PE.

Implementing a Pediatric Pulmonary Embolism Response Team Model: An Institutional Experience

Pulmonary embolism is increasing in prevalence among pediatric patients; although still rare, it can create a significant risk for morbidity and death within the pediatric patient population. Pulmonary embolism presents in various ways depending on the patient, the size of the embolism, and the comorbidities. Treatment decisions are often driven by the severity of the presentation and hemodynamic effects; severe presentations require more invasive and aggressive treatment. We describe the development and implementation of a pediatric pulmonary embolism response team designed to facilitate rapid, multidisciplinary, data-driven treatment decisions and management.

Update on Pediatric Nuclear Medicine in Acute Care

Various radiopharmaceuticals are available for imaging pediatric patients in the acute care setting. This article focuses on the common applications used on a pediatric patient in acute care. To confirm the clinical diagnosis of brain death, brain scintigraphy is considered accurate and has been favorably compared with other methods of detecting the presence or absence of cerebral blood flow. Ventilation-perfusion lung scans are easy and safe to perform with less radiation exposure than computed tomography pulmonary angiography and remain an appropriate procedure to perform on children with suspected pulmonary embolism as a first imaging test in a hemodynamically stable patient with no history of lung disease and normal chest radiograph. 99mTc-pertechnetate scintigraphy (Meckel's scan) is the best noninvasive procedure to establish the diagnosis of ectopic gastric mucosa in Meckel's diverticulum. 99mTcred blood cell scintigraphy generally is useful for assessing lower GI bleeding in patients from any cause. Hepatobiliary scintigraphy is the most accurate diagnostic imaging modality for acute cholecystitis. 99mTc-dimercaptosuccinic acid scintigraphy is the simplest, and the most reliable and sensitive method for the early diagnosis of focal or diffuse functional cortical damage. 99mTcmercaptoacetyltriglycine scintigraphy is used to evaluate for early and late complications of renal transplantation. Bone scintigraphy is a sensitive and noninvasive technique for diagnosis of bone disorders such as osteomyelitis and fracture. 18F-fluorodeoxyglucose-positron emission tomography could be valuable in the evaluation of fever of unknown origin in pediatric patients, with better sensitivity and significantly less radiation exposure than a gallium scan. Moving forward, further refinement of pediatric radiopharmaceutical administered activities, including dose reduction, greater radiopharmaceutical applications, and updated consensus guidelines is warranted, with the use of radionuclide imaging likely to increase.

Return emergency department visits for recurrent pulmonary embolism symptoms in children and adolescents

Rates of pulmonary embolism (PE) in children have steadily increased over the past 2 decades. Patient outcomes after hospital discharge are poorly understood, and many patients experience recurrent or persistent chest pain or dyspnea, prompting a return to care. This retrospective cohort study of patients diagnosed with PE at a large children's hospital over a 9.5-year period was performed to evaluate rates of return to the emergency department (ED) for PE-related symptoms, and to determine the utility of repeat computed tomography angiography (CTA) in this population. Ninety-six patients were diagnosed with PE during the study period. Forty-two percent of patients (n = 40) returned to the ED for PE-related symptoms and a total of 74 repeat CTAs were performed. Among those who had return visits, the mean number of return visits was 3 and the mean number of repeat CTAs was 1.8. The median time to return to the ED was 34 days. Logistic regression analysis identified increased age and female sex as risk factors for return ED visits. Eight percent of the cohort experienced PE recurrence. Recurrent PE was observed only in those with persistent or new thrombotic risk factors and was uncommon in those who remained on appropriate anticoagulation. Future work should focus on the development of a risk stratification system to identify patients at low risk of recurrence in order to minimize repeat CTA imaging.

Drug-Delivery Silver Nanoparticles: A New Perspective for Phenindione as an Anticoagulant

Anticoagulants prevent the blood from developing the coagulation process, which is the primary cause of death in thromboembolic illnesses. Phenindione (PID) is a well-known anticoagulant that is rarely employed because it totally prevents coagulation, which can be a life-threatening complication. The goal of the current study is to synthesize drug-loaded Ag NPs to slow down the coagulation process. Methods: A rapid synthesis and stabilization of silver nanoparticles as drug-delivery systems for phenindione (PID) were applied for the first time. Results: Several methods are used to determine the size of the resulting Ag NPs. Additionally, the drug-release capabilities of Ag NPs were established. Density functional theory (DFT) calculations were performed for the first time to indicate the nature of the interaction between PID and nanostructures. DFT findings supported that galactose-loaded nanostructure could be a proper delivery system for phenindione. The drug-loaded Ag NPs were characterized in vitro for their antimicrobial, cytotoxic, and anticoagulant activities, and ex vivo for spasmolytic activity. The obtained data confirmed the drug-release experiments. Drug-loaded Ag NPs showed that prothrombin time (PT, sec) and activated partial thromboplastin time (APTT, sec) are approximately 1.5 times longer than the normal values, while PID itself stopped coagulation at all. This can make the PID-loaded Ag NPs better therapeutic anticoagulants. PID was compared to PID-loaded Ag NPs in antimicrobial, spasmolytic activity, and cytotoxicity. All the experiments confirmed the drug-release results.

A retrospective study of the clinical characteristics of 9 children with pulmonary embolism associated with Mycoplasma pneumoniae pneumonia

OBJECTIVE

The aim of this study was to analyze the clinical characteristics and treatment of children with Mycoplasma pneumoniae pneumonia (MPP) who also present with pulmonary embolism (PE).

METHODS

This retrospective analysis examined the demographic data, clinical manifestations, laboratory tests, imaging characteristics, therapy, and prognosis of nine cases of children with Mycoplasma pneumoniae pneumonia (MPP) complicated by pulmonary embolism (PE). The study focused on patients admitted to the respiratory department of Tianjin Children's Hospital between January 2018 and December 2021.

RESULTS

The age range of the patients was 3 to 8 years old, with a median age of 7.5 years. The median number of days from pulmonary infection to the diagnosis of embolism was 14 days. All patients had refractory Mycoplasma pneumoniae pneumonia (RMPP). Among them, three patients reported chest pain, one of whom had hemoptysis, while five patients had dyspnea, and six patients experienced radiating pain at unusual sites. Five out of the nine children tested positive for lupus anticoagulant (LA), five for anticardiolipin antibody (ACA), three for anti-2-glycoprotein antibody IgM, four for reduced protein S or protein C activity, and three for elevated coagulation factor VIII. Moreover, six out of the nine children tested positive for antinuclear antibodies. All the children underwent CT pulmonary angiograms, which revealed filling defects. After sequential low-molecular heparin anticoagulation with rivaroxaban, nine children in this study showed a good prognosis, with two of them receiving thrombolytic therapy for combined cardiac embolism. Follow-up at 0.5-9 months showed the gradual resolution of the emboli in all 9 children, with no thrombotic recurrences and normalized autoantibodies and thrombophilia markers.

CONCLUSIONS

The majority of cases involving Mycoplasma pneumoniae pneumonia (MPP) combined with pulmonary embolism (PE) were diagnosed with refractory MPP (RMPP). However, PE did not always occur in the advanced stages of the disease. Most patients presented with transient autoantibody positivity, abnormal coagulation, and fibrinolytic balance. With timely treatment, the prognosis of MPP combined with PE is generally good. Additionally, rivaroxaban treatment has been shown to be safe and effective.

Pulmonary embolism in pediatrics: A 10-year experience from a tertiary center in Brazil

INTRODUCTION

Although still rare, pulmonary embolism (PE) in children has been increasing over the years. Data regarding this group of patients are still sparse, which contributes to the lack of standardized prophylaxis protocols and the misdiagnosis. This study aimed to determine the incidence of pediatric PE at a Brazilian tertiary hospital, describe clinical characteristics and identify possible risk factors. We also analyzed the diagnosis and management of PE.

METHODS

This was a retrospective review of tertiary Brazilian single-center data of all pediatric patients (0 - 18 years) with acute PE, diagnosed radiologically, from September 2009 to May 2019.

RESULTS

The incidence of PE was 3.3 cases per 10,000 hospitalized children. All the twenty-three cases had some risk factor identified and sixteen of them (69.5%) had more than one risk factor. The most important were central venous catheter (39.1%), malignancy (34.8%) and recent surgery (34.8%). Among the children with identifiable symptoms (69.5%), the most common was dyspnea (56.2%). Only one patient did not receive antithrombotic therapy because of the high bleeding risk and most patients (70.6%) were treated for 3 to 6 months. Among the nineteen patients alive at the end of the six-month follow-up, ten (52.6%) repeated the PE image control. Seven of them (70.0%) had complete or partial resolution of the thrombosis and none had worsening images.

CONCLUSION

Our lower incidence than that of the current literature may reflect underdiagnosis due to low suspicion of PE. At least one risk factor was identified in all patients, which emphasizes the importance of increasing awareness of high-risk children.

High Rates of Pediatric Venous Thromboembolism After Elective Laparoscopic Splenectomy Suggest Need for Perioperative Prophylaxis

INTRODUCTION

In adult populations, postoperative venous thromboembolism (VTE) is a reported complication of up to 8% of elective laparoscopic splenectomy (LS) cases. VTE is a rare event in the pediatric population, affecting less than 1% of all pediatric surgical patients. We hypothesized that pediatric patients are at a higher risk of postoperative VTE after undergoing elective LS relative to other laparoscopic procedures and may warrant prophylactic treatment.

MATERIALS AND METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database from 2012 to 2020. Patients were identified using the Current Procedural Terminology code 38120 and only elective cases were analyzed.

RESULTS

The incidence of VTE in all pediatric patients undergoing surgery in the American College of Surgeons NSQIP-P database was 0.13%. The incidence of VTE in pediatric patients undergoing elective laparoscopic abdominopelvic procedures was 0.17%. There were seven total cases of VTE (0.41%) in pediatric patients undergoing elective LS, more than twice the rate of the general population (P = 0.001). Eighty percent of pediatric patients undergoing elective LS had an underlying hematological disorder.

CONCLUSIONS

By analyzing the NSQIP-P database, we evaluated the largest cohort of pediatric patients undergoing elective LS to date. We identified a higher incidence of VTE following this procedure relative to the rate of VTE in the overall population in the NSQIP-P database, as well as those undergoing elective laparoscopic abdominopelvic operations. The relatively higher incidence of VTE after elective LS is likely due to the presence of underlying hematological conditions. Given the low incidence of complications associated with pharmacologic VTE prophylaxis, the results of this study suggest that further research is warranted to establish the efficacy of perioperative pharmacological VTE prophylaxis in pediatric patients undergoing elective LS.

Prevalence and Risk Factors for Pulmonary Embolism in Pediatric Sickle Cell Disease: A National Administrative Database Study

Patients with sickle cell disease (SCD) have a high risk for venous thromboembolism which is associated with increased risk of mortality. Studies examining risk of pulmonary embolism (PE) in children with SCD are lacking. This study was conducted in children with SCD between 0-21 years of age using a nationwide administrative database in the United States- Pediatric Health Information System (PHIS) from January 2010 to June 2021. Diagnostic codes and imaging, procedure, and pharmaceutical billing codes were used to identify PE and potential clinical, demographic, and utilization risk factors. Logistic regression analyses were performed to assess association between risk factors and PE. We identified 22,631 unique patients with SCD with a median age of 10.8 years (range: <0.1-20.9). A total of 120 (0.53%) patients developed a PE with median age of 17.4 years (range: 6.6-20.9) at PE diagnosis. Patients with PE had longer hospitalization and more frequent ICU admissions than patients without PE (p < 0.001). Risk factors significantly associated with PE on multivariable analysis included older age, prior history of central venous line (CVL), acute chest syndrome, and apheresis. Mortality was not significantly different between those with and without PE. The prevalence of PE in hospitalized children with SCD was estimated to be 0.53%. Patients with PE had higher healthcare utilization characteristics. Factors significantly associated with PE suggest that the risk for PE in SCD may be related to the severity of disease state. Future trials are needed for risk stratification and PE prevention strategies in children with SCD.

The utility of risk assessment tools for acute pulmonary embolism in children

BACKGROUND AND AIM: Pulmonary embolism (PE) is a potentially life-threatening disease in children. The objective of the study is to evaluate the utility of adult-based pulmonary embolism rule-out criteria (PERC), Pediatric PE Model, and D-dimer in the diagnosis of PE in children.

MATERIAL AND METHODS

The study consisted of patients under 18 years of age who were consulted to the Pediatric Pulmonology Clinic for the evaluation of PE. Patients were divided into two groups based on the confirmation of PE. The group with the presence of PE (n = 20) consisted of children who were diagnosed with PE. The group with the absence of PE (n = 28) consisted of children with clinically suspected PE but negative diagnostic imaging. Adult validated clinical decision PERC rule and Pediatric PE Model were retrospectively applied to the patients.

RESULTS

In the study, PERC demonstrated a sensitivity of 60% and a specificity of 46% for the diagnosis of PE in children. When PE Model was evaluated for the children, it was found a 50% sensitivity and 75% specificity. Combining PE Model and PERC rule with D-dimer did not increase the specificity and sensitivity. Smoking was found to be relevant for PE in the childhood. Twenty-five percent of the patients had a genetic tendency for PE. All of the patients had an underlying disease as well.

CONCLUSION

None of the current risk assessment tools (PE Model, PERC, D-dimer) were found to be accurate in predicting PE. Further larger population studies are still required to develop a better diagnostic approach.

Acute Management of High-Risk and Intermediate-Risk Pulmonary Embolism in Children: A Review

Severe forms of pulmonary embolism (PE) in children, althought rare, cause significant morbidity and mortality. We review the pathophysiologic features of severe (high-risk and intermediate-risk) PE and suggest novel pediatric-specific risk stratifications and an acute treatment algorithm to expedite emergent decision-making. We defined pediatric high-risk PE as causing cardiopulmonary arrest, sustained hypotension, or normotension with signs or symptoms of shock. Rapid primary reperfusion should be pursued with either surgical embolectomy or systemic thrombolysis in conjunction with a heparin infusion and supportive care as appropriate. We defined pediatric intermediate-risk PE as a lack of systemic hypotension or compensated shock, but with evidence of right ventricular strain by imaging, myocardial necrosis by elevated cardiac troponin levels, or both. The decision to pursue primary reperfusion in this group is complex and should be reserved for patients with more severe disease; anticoagulation alone also may be appropriate in these patients. If primary reperfusion is pursued, catheter-based therapies may be beneficial. Acute management of severe PE in children may include systemic thrombolysis, surgical embolectomy, catheter-based therapies, or anticoagulation alone and may depend on patient and institutional factors. Pediatric emergency and intensive care physicians should be familiar with the risks and benefits of each therapy to expedite care. PE response teams also may have added benefit in streamlining care during these critical events.

Reassessing the Pediatric Dosing Recommendations for Unfractionated Heparin Using Real-World Data: a Pharmacokinetic-Pharmacodynamic Modeling Approach

Optimal pediatric dosing of unfractionated heparin (UFH) is challenging due to paucity of clinical outcome and pharmacokinetic-pharmacodynamic (PK/PD) studies in pediatrics. This study aimed to: (i) develop a PK/PD model for UFH, quantified by anti-factor Xa assay and the UFH effect measured by activated partial thromboplastin time (aPTT) (ii) evaluate pediatric UFH infusions in achieving anti-factor Xa (0.3 - 0.7 IU/mL) therapeutic target by simulations. Electronic health record data were retrospectively collected from 633 patients < 19 years old admitted to Texas Children's Hospital. The PK/PD model was developed using a 70% (training)-30% (test) data split approach. A one-compartment PK model with linear elimination adequately described the UFH PK. An allometrically scaled body weight on clearance (CL) and volume of distribution (Vd) with an age-dependent maturation function of extracellular water on Vd were the covariates identified. Comparable with literature, the typical values for CL and Vd were 3.28 L/(hr·50 kg) and 8.83 L/50 kg, respectively. A linear model adequately described the UFH-aPTT relationship with an estimated slope of 150. Simulations of the currently recommended starting infusions (28 IU/hr/kg for pediatrics < 1 year old or 20 IU/hr/kg for pediatrics > 1 year old) showed that anti-factor Xa therapeutic target was achieved only in 15.3%, 14.6%, 36.9% and 45.11% of subjects in the age groups of < 1 year, 1-6 years, 6-12 years, and 12-19 years, respectively. In conclusion, the UFH anti-factor Xa target is not achieved initially especially in young pediatrics, suggesting the need to optimize UFH dosing to achieve higher therapeutic success. This article is protected by copyright. All rights reserved.

Superior Mesenteric Vein Thrombosis in a Pediatric Patient: Case Report and Review of the Literature

ABSTRACT

Patients with inflammatory bowel disease are at increased risk of thromboembolism. There are various sites for thromboembolism including the cerebral, limbs, abdominal vessels, retina, and lungs. Here, we report a case of a 17-year-old patient with a history of Crohn disease presenting with abdominal pain. Upon further evaluation, the patient was found to have mesenteric vein thrombosis, which was discovered on computed tomographic scan. Potential causes, contributing factors, diagnosis, and treatment are discussed here.

Comparison of septic and nonseptic pulmonary embolism in children

BACKGROUND

Septic pulmonary embolism (SPE) in children is a rare disease. Data are scarce regarding the clinical and laboratory manifestation of SPE compared with nonseptic pulmonary embolism (ns-PE). Furthermore, specific guidelines for the management of SPE in children are lacking.

AIM

We compared the clinical course and outcome of children with SPE and ns-PE.

METHODS

A retrospective, cohort study of hospitalized children, 2005-2020, with documented pulmonary embolism imaging.

RESULTS

Sixteen children (eight SPE, eight ns-PE) were identified. Episodes of SPE occurred secondary to endocarditis, musculoskeletal and soft tissue infections, with Staphylococcus aureus (n = 4) and streptococcus spp. (n = 2) as the most common pathogens. Radiographically, SPE presented as a microvascular disease with parenchymatic nodules/cavitations, whereas ns-PE presented as larger vessel disease with filling defects. Risk factors (including thrombophilia) were noted in 0% and 87.5% of SPE and ns-PE patients, respectively (p < .01). Pulmonary embolism diagnosis was delayed in SPE compared with ns-PE (median: 8.5 days vs. 1 day). The SPE group had higher rates of fever (100% vs. 12.5%, p < .01), C-reactive protein (CRP levels; 18.49 vs. 4.37 mg/dl, p = .02), and fibrinogen levels (880 vs. 467 mg/dl, p < .001). Antithrombotic treatment for >4 months was administrated to 14.3% and 87.5% of SPE and ns-PE patients, respectively (p < .01). One ns-PE patient had a second thromboembolic event compared to none in the SPE group.

CONCLUSIONS

SPE in children is a unique subgroup of PE with different clinical and laboratory findings that requires a different diagnostic approach and probably shorter duration of antithrombotic treatment.

Pulmonary embolism in pediatric age: A retrospective study from a tertiary center

INTRODUCTION

Pediatric pulmonary embolism (PE) is rare but associated with adverse outcomes. We aimed to characterize PE cases admitted in a tertiary hospital and to evaluate sensitivity of selected PE diagnostic prediction tools.

METHODS

Retrospective, descriptive study of PE cases admitted from 2008 to 2020 using data collected from hospital records. Patients were grouped according to PE severity and setting (outpatients vs. inpatients). Links and correlation with demographic characteristics, risk factors, clinical presentation, management, and outcomes were analyzed. PE diagnostic prediction tools were applied.

RESULTS

Twenty-nine PE episodes occurred in 27 patients, 62.9% female, mean age 14.1 years. Most PE were central and split between massive or submassive. One was diagnosed in autopsy. Twenty outpatients, all adolescents, were admitted for classic PE symptoms; in half of them the diagnosis had been previously missed. Risk factors included contraceptives (65%), thrombophilia (35%), obesity (20%) and auto-immunity (20%). Eight inpatients, diagnosed during cardiorespiratory deterioration (n = 5), or through incidental radiological findings (n = 3), were younger and had immobilization (87.5%), complex chronic diseases (75%), infections (75%) and central venous catheter (62.5%) as risk factors. Retrospectively, d -dimer testing and adult scores performed better than pediatric scores (sensitivity 92.9%-96% vs. 85.7%-92.9%). Both pediatric scores missed a case with a positive family history.

DISCUSSION

Pediatric PE diagnosis is often delayed or missed. Development of pediatric prediction tools from validated adult scores merits being explored. We argue clinical presentation and risk factors may be different in inpatients and outpatients and propose broader reliance on family history.

Pulmonary Embolism in a Critically Ill Infant with Univentricular Parallel Circulation

A 3-month-old infant patient with hypoplastic left heart syndrome diagnosed in the prenatal period required long-term intensive care for refractory chylothorax and chylous ascites after undergoing bilateral pulmonary artery banding at age 6 days. Weaning from mechanical ventilation was difficult due to massive edema, and a central venous catheter was required because enteral feeding was hampered by the refractory chyle leakage, for which surgery was ineffective. On the evening after central venous catheter replacement was performed, his respiratory condition suddenly deteriorated; cardiac ultrasound revealed that the left pulmonary arterial blood flow had decreased, and enhanced computed tomography demonstrated a left pulmonary embolism (PE), which was identified as the cause of a sudden decrease in the pulmonary blood flow. The patient died due to refractory septic shock at age 5 months. PEs in children, especially patients with cyanotic congenital heart disease, are difficult to diagnose because of their atypical presentation. Current diagnostic criteria are based on adult guidelines, and a few factors in the criteria, such as tachycardia and hypoxia, are difficult to apply for pediatric cyanotic patients with intracardiac or extracardiac right-to-left shunt. In fact, those criteria have lower specificities in children. In conclusion, the present case suggested that a sudden decrease in the pulmonary blood flow can aid the physicians in diagnosing PE in patients with cyanotic congenital heart disease. We need more pediatric cases and evidence of PE in children to make a PE guideline, which is specific to pediatric patients including cyanotic congenital heart disease.

Prediction and Diagnosis of Venous Thromboembolism Using Artificial Intelligence Approaches: A Systematic Review and Meta-Analysis

Venous thromboembolism (VTE) is a fatal disease and has become a burden on the global health system. Recent studies have suggested that artificial intelligence (AI) could be used to make a diagnosis and predict venous thrombosis more accurately. Thus, we performed a meta-analysis to better evaluate the performance of AI in the prediction and diagnosis of venous thrombosis. PubMed, Web of Science, and EMBASE were used to identify relevant studies. Of the 741 studies, 12 met the inclusion criteria and were included in the meta-analysis. Among them, 5 studies included a training set and test set, and 7 studies included only a training set. In the training set, the pooled sensitivity was 0.87 (95% CI 0.79-0.92), the pooled specificity was 0.95 (95% CI 0.89-0.97), and the area under the summary receiver operating characteristic (SROC) curve was 0.97 (95% CI 0.95-0.98). In the test set, the pooled sensitivity was 0.87 (95% CI 0.74-0.93), the pooled specificity was 0.96 (95% CI 0.79-0.99), and the area under the SROC curve was 0.98 (95% CI 0.97-0.99). The combined results remained significant in the subgroup analyzes, which included venous thrombosis type, AI type, model type (diagnosis/prediction), and whether the period was perioperative. In conclusion, AI may aid in the diagnosis and prediction of venous thrombosis, demonstrating high sensitivity, specificity and area under the SROC curve values. Thus, AI has important clinical value.

Venous Thromboembolism among Critically Ill Children: A Narrative Review

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.

Community-Onset Venous Thromboembolism in Children: Pediatric Emergency Medicine Perspectives

Pediatric venous thromboembolism (VTE) is a condition increasingly encountered by emergency medicine physicians. Unfortunately, despite increased incidence, the diagnosis of pediatric VTE relies on a high index of suspicion from clinicians. Delays in diagnosis and initiation of treatment can lead to poor outcomes in children, including an increased risk of mortality from pulmonary embolism, increased risk of VTE recurrence, and the development of the post-thrombotic syndrome. The majority of pediatric VTE events are associated with the presence of at least one underlying prothrombotic risk. Timely recognition of these risk factors in the emergency department (ED) setting is paramount for a prompt diagnosis and treatment initiation. Compared with children with hospital-acquired VTE, children presenting to the ED with new onset VTE tend to be older (>11 years of age), have a lower incidence of co-morbidities, and present more frequently with a deep venous thrombosis of the lower extremity. Currently, there are no validated pediatric-specific VTE clinical pretest probability tools that reliably assist with the accurate and timely diagnosis of pediatric VTE. Compression ultrasound with Doppler is the most common imaging modality used for VTE diagnosis, and low molecular weight heparins are the most common anticoagulants initiated in children presenting with VTE in the ED. Special consideration should be given to patients who present to the ED already on anticoagulation therapy who may require acute management for clinically-significant bleeding or change in antithrombotic therapy approach for progression/recurrence of VTE.

Inferior Vena Cava Filter in Childhood Septic Deep Vein Thrombosis

Inferior vena cava (IVC) filter in venous thromboembolism (VTE) is an alternative to anticoagulation when the latter is contraindicated. The use of IVC filter in pediatrics continues to be rare and has not increased despite the ever-increasing rates of childhood VTE. Historically, septic VTE was regarded as a contraindication to IVC filter. Safety and efficacy of IVC filters in septic VTE have been reported in adult patients but not in pediatric patients. In this study, we reported a safe use of IVC filter in a critically ill 12-year-old patient with a large IVC thrombus and multiple pulmonary embolisms with favorable outcome.

Pulmonary artery thromboembolism in a critically ill neonate successfully treated using thrombolytic therapy

Pulmonary artery thromboembolism is a common and treatable cause of adult pulmonary hypertension. Although rare in children, if undiagnosed, it can result in significant morbidity and mortality. We report a case of a cyanotic neonate found to have bilateral pulmonary arterial thrombi who successfully underwent thrombolysis using tissue plasminogen activator with prompt resolution of right ventricular hypertension.

CTA utilization for evaluation of suspected pulmonary embolism in a tertiary pediatric emergency department

OBJECTIVE

To evaluate changes in the utilization of computed tomography angiography (CTA) for evaluating suspected pulmonary embolism (PE) and the positive rate of ancillary for those studies negative for PE in the last 13 years.

MATERIALS AND METHODS

A retrospective review of patient ≤ 20 years of age who underwent a chest CT angiography to rule out PE was performed in a 13-year-period. CT angiographies were grouped into three categories: Positive for PE, negative for PE and positive for ancillary findings, and negative for any pathology. From the exams with ancillary findings, we examined how many of these had a chest radiograph perform within 24 h prior to the CTA and how many of them had an impression stating the same conclusion as the CTA.

RESULTS

307 chest CT angiographies for suspected PE were included. 50 (16%) were reported as positive for PE and 91 (30%) were negative for PE but positive for ancillary findings. The most frequent ancillary findings were pneumonia (n = 26) and pleural effusion (n = 11). Out of 91, 73 patients had a previous chest radiograph and 28 of them reported a similar diagnosis than the CTA. The number of CT angiographies indicated for PE increased by 3.2 studies per year. The rate of CT angiographies positive for ancillary findings (slope = 1.5) and positive for PE (slope = 0.3) remained similar throughout the same period.

CONCLUSIONS

CTA orders for PE have been increasing without any increased detection of PE or ancillary findings in children.

Risk factors for the development of hospital-acquired pediatric venous thromboembolism-Dealing with potentially causal and confounding risk factors using a directed acyclic graph (DAG) analysis

Introduction

Hospital-acquired venous thromboembolism (HA-VTE) in children comprises multiple risk factors that should not be evaluated separately due to collinearity and multiple cause and effect relationships. This is one of the first case-control study of pediatric HA-VTE risk factors using a Directed Acyclic Graph (DAG) analysis.

Material and methods

Retrospective, case-control study with 22 cases of objectively confirmed HA-VTE and 76 controls matched by age, sex, unit of admission, and period of hospitalization. Descriptive statistics were used to define distributions of continuous variables, frequencies, and proportions of categorical variables, comparing cases and controls. Due to many potential risk factors of HA-VTE, a directed acyclic graph (DAG) model was created to identify confounding, reduce bias, and increase precision on the analysis. The final model consisted of a DAG-informed conditional logistic regression.

Results

In the initial conventional univariable model, the following variables were selected as potential risk factors for HA-VTE: length of stay (LOS, days), immobility, ICU admission in the last 30 days, LOS in ICU, infection, central venous catheter (CVC), number of CVCs placed, L-asparaginase, heart failure, liver failure, and nephrotic syndrome. The final model using the set of variables selected by DAG analysis revealed LOS (OR = 1.106, 95%CI = 1.021–1.198, p = 0.013), L-asparaginase (OR = 26.463, 95%CI = 1.609–435.342, p = 0.022), and nephrotic syndrome (OR = 29.127, 95%CI = 1.044–812.508, p = 0.004) as independent risk factors for HA-VTE.

Conclusion

The DAG-based approach was useful to clarify the influence of confounders and multiple causalities of HA-VTE. Interestingly, CVC placement—a known thrombotic risk factor highlighted in several studies—was considered a confounder, while LOS, L-asparaginase use and nephrotic syndrome were confirmed as risk factors to HA-VTE. Large confidence intervals are related to the sample size; however, the results were significant.

Prevention of Venous Thromboembolism in 2020 and Beyond

Venous thromboembolism (VTE) is the third most common cause of vascular mortality worldwide and comprises deep-vein thrombosis (DVT) and pulmonary embolism (PE). In this review, we discuss how an understanding of VTE epidemiology and the results of thromboprophylaxis trials have shaped the current approach to VTE prevention. We will discuss modern thromboprophylaxis as it pertains to genetic risk factors, exogenous hormonal therapies, pregnancy, surgery, medical hospitalization, cancer, and what is known thus far about VTE in COVID-19 infection.

Pulmonary embolism in acute lymphoblastic leukemia - An observational study of 1685 patients treated according to the NOPHO ALL2008 protocol

BACKGROUND

Pulmonary embolism (PE) is a serious complication of acute lymphoblastic leukemia (ALL). We examined the cumulative incidence and clinical presentation of PE in a well-defined cohort of patients with ALL aged 1-45 years treated according to the Nordic Society of Pediatric Hematology and Oncology (NOPHO) ALL2008 protocol.

METHODS

As part of the mandatory toxicity reporting of NOPHO ALL2008, thromboembolism including PE was reported consecutively. The cumulative incidence of first-time PE was calculated using the Aalen-Johansen estimator during a 2.5-year period from ALL diagnosis. We used Fisher's exact test to examine categorical variables and Cox logistic regression to estimate hazard ratios (HRs) for PE.

RESULTS

PE was diagnosed in 32 of 1685 patients. The 2.5-year cumulative incidence of first-time PE increased with age: 0.43% (95% CI, 0.18-1.03) in children aged 1-9 years, 3.28% (95% CI, 1.72-6.22) in children aged 10-17 years, and 7.22% (95% CI, 4.61-11.21) in adults aged 18-45 years. The majority of PEs, 78% (25/32), occurred during asparaginase treatment. HRs adjusted for age and sex were associated with male sex (HR, 2.4; 95% CI, 1.0-5.6) and older age (10-17 years: HR 7.5; 95% CI, 2.5-22.2), 18-45 years: HR, 16.5; 95% CI, 6.1-44.5). In two-thirds of the patients (63%; 17/27), PE and its treatment had no impact on the administered doses of asparaginase. PE-associated 30-day mortality was 9.4% (95% CI, 1.9-25.0).

CONCLUSIONS

Awareness of PE is warranted during ALL treatment. Larger multicenter studies are needed to examine predictors of PE in ALL.

Perioperative Transfusions and Venous Thromboembolism

BACKGROUND AND OBJECTIVES

Annual incidence of venous thromboembolism (VTE) including postoperative VTE in hospitalized children is rising significantly. A growing body of evidence supports the role of red blood cells (RBCs) in pathologic thrombosis. In this study, we examined the association of perioperative RBC transfusion with postoperative VTE in pediatric patients.

METHODS

The pediatric databases of the American College of Surgeons' National Surgical Quality Improvement Project from 2012 to 2017 were used. Multivariable logistic regression was used to examine the association between perioperative RBC transfusion status and the development of new or progressive VTE within 30 days of surgery. The analyses were age stratified, as follows: neonates (≤28 days), infants (>28 days and <1 year), and children (≥1 year).

RESULTS

In this study, we included 20 492 neonates, 79 744 infants, and 382 862 children. Postoperative development of VTE was reported in 99 (0.48%) neonates, 147 (0.2%) infants, and 374 (0.1%) children. In all age groups, development of VTE was significantly more common among patients with a perioperative RBC transfusion than patients without a perioperative RBC transfusion (neonates: adjusted odds ratio [aOR] = 4.1, 95% confidence interval [CI] = 2.5-6.7; infants: aOR = 2.4, 95% CI = 1.7-3.6; children: aOR = 2.2, 95% CI = 1.7-2.9). Among children who received an intra- or postoperative transfusion, the weight-based volume of RBCs (mL/kg) transfused was associated with postoperative VTE in a dose-dependent manner: second tertile (odds ratio = 2.3, 95% CI = 1.3-4.1) and third tertile (odds ratio = 4.1, 95% CI = 2.3-7.4) versus first tertile.

CONCLUSIONS

Perioperative RBC transfusions are independently associated with development of new or progressive postoperative VTE in children, infants, and neonates. These findings need further validation in prospective studies and emphasize the need for evidence-based perioperative pediatric blood transfusion decisions.

Catheter-directed thrombolysis for submassive pulmonary embolism in children: A case series

Incidence of venous thromboembolism, including pulmonary embolism (PE), continues to rise in children. Optimum management of submassive PE is unclear. The principal objective of this retrospective study was to investigate the radiological and clinical outcomes in children with submassive PE treated with catheter-directed thrombolysis (CDT). Five patients underwent six episodes of CDT. No patient developed major/clinically relevant non-major bleeding. Most patients had complete radiological thrombus resolution and no patient had evidence of chronic thromboembolic pulmonary hypertension. There is an urgent need for larger prospective cohort studies/randomized controlled trials to investigate the role of CDT in pediatric PE.

Pulmonary Embolism Can Be Nauseous: A Case Report and Review of D-Dimer Use in Pediatric Oncology Patients

BACKGROUND

Pulmonary embolism (PE) is a very common presentation in the emergency department (ED). Despite being life-threatening, PE is preventable if diagnosed and managed early, especially in high-risk patients like pediatric oncology patients. A negative d-dimer has a high negative predictive value and can rule out PE in low-risk patients; however, it does not lower post-test probability enough and should be coupled with further diagnostics in high-risk patients.

CASE REPORT

We describe the case of a 14-year-old girl known to have acute lymphoblastic leukemia and presented to the ED with persistent nausea and vomiting only, which was exacerbated by exertion. She had previously presented to the ED 1 week earlier for the same complaint, with a nonrevealing physical examination. At that time, the patient was worked up for nausea and vomiting and received symptomatic treatment. An electrocardiogram (ECG) during that presentation showed normal sinus rhythm. During this presentation, ECG showed new ST segment depressions from V1 to V6 in addition to an S1Q3T3 pattern. This, coupled with the exacerbation of her initial symptoms, triggered further investigations. Computed tomography angiography (CTA) of the chest was performed and showed a right lower lobe segmental pulmonary artery embolus. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the importance of having a high level of suspicion for PE, especially in pediatric oncology patients and specifically in hematologic malignancies. Although our patient's presentation, examination, and laboratory results were not concerning initially, CTA of the chest showed a PE. We are addressing this particular topic to increase the awareness of emergency physicians of cases like this, as PE can have an unusual presentation and missing such a diagnosis can be fatal.

Catheter-Directed Pharmacologic Thrombolysis for Acute Submassive and Massive Pulmonary Emboli in Children and Adolescents-An Exploratory Report

OBJECTIVES

The objective of this study is to report a single-center experience of the safety and efficacy of pulmonary artery catheter-directed thrombolysis for both massive and submassive pulmonary emboli in the pediatric and adolescent population.

DESIGN

A 22-month retrospective review of the electronic medical record and picture archiving and communication system was performed of patients less than 21 years old, presenting with massive or submassive pulmonary emboli treated with pulmonary artery catheter-directed thrombolysis at a single, tertiary care pediatric hospital. Multiple variables were analyzed including indications, technical success, clinical efficacy, and complications.

SETTING

A single, tertiary care pediatric hospital.

PATIENTS

Nine patients (mean 13.9 yr; range 6-19 yr) with massive and/or submassive pulmonary emboli who underwent pulmonary artery catheter-directed thrombolysis met inclusion criteria.

INTERVENTIONS

Catheter-directed thrombolysis.

MEASUREMENTS AND MAIN RESULTS

Pulmonary emboli was diagnosed by CT angiography in all cases. Catheter-directed thrombolysis alone was clinically successful (defined as improved cardiopulmonary function following catheter-directed thrombolysis) in seven patients (78%) with two patients not improving following catheter-directed thrombolysis. There were no immediate bleeding complications from catheter-directed thrombolysis therapy. All patients were maintained on anticoagulation treatment following catheter-directed thrombolysis. Catheter-directed thrombolysis was technically successful (defined as successful placement of pulmonary artery infusion catheters with full or partial resolution of thrombus) in all cases. Follow-up pulmonary angiography at the cessation of catheter-directed thrombolysis revealed complete thrombus resolution in four patients (44%) and partial resolution in five patients (55%). Mean pulmonary artery pressures decreased in all patients (mean precatheter-directed thrombolysis pulmonary artery pressure = 37 ± 11 mm Hg; mean postcatheter-directed thrombolysis pulmonary artery pressure = 28 ± 10 mm Hg; p = 0.0164).

CONCLUSIONS

Pulmonary artery catheter-directed thrombolysis is a technically feasible therapeutic option for children and adolescents with submassive and massive pulmonary emboli.

Fatal rare case of measles complicated by bilateral pulmonary embolism: a case report and short literature review

Different endemic outbreaks of measles have been diagnosed worldwide during the last several years. Some have had severe and fatal complications, possibly because of decreasing vaccination rates. The present case report describes an unvaccinated boy aged 2 years 11 months who was diagnosed with severe measles complicated by pulmonary embolism (PE). Clinical examination revealed a maculopapular rash, hyperemic pharynx, Koplik’s spots, upper respiratory airway obstruction, and tachycardia with no meningeal signs of irritation. Laboratory investigations showed leukocytosis, anemia, normal liver enzyme levels, a moderately high C-reactive protein level (26 mg/L), a high erythrocyte sedimentation rate (65 mm/h), and immunoglobulin M positivity for measles. The patient was treated with antibiotic therapy (meropenem at 20 mg/kg every 8 hours) and supportive measures (anti-inflammatory drugs and intravenous rehydration). On the fourth day of hospitalization, the patient’s general condition became profoundly altered; although cardiorespiratory resuscitation maneuvers were initiated, the child died. Autopsy revealed bilateral pleural effusion with serous citrine fluid, acute purulent bronchopneumonia, bilateral hilar adenopathy, and bilateral PE. Additional research is needed to establish optimal care for pediatric patients with measles, especially when complicated by PE.

Venous thromboembolism following inpatient pediatric surgery: Analysis of 153,220 patients

PURPOSE

To evaluate venous thromboembolism (VTE) rates and risk factors following inpatient pediatric surgery.

METHODS

153,220 inpatient pediatric surgical patients were selected from the 2012-2015 NSQIP-P database. Demographic and perioperative variables were documented. Primary outcome was VTE requiring treatment within 30 postoperative days. Secondary outcomes included length of stay (LOS) and 30-day mortality. Prediction models were generated using logistic regression. Mortality and time to VTE were assessed using Kaplan-Meier survival analysis.

RESULTS

305 patients (0.20%) developed 296 venous thromboses and 12 pulmonary emboli (3 cooccurrences). Median time to VTE was 9 days. Most VTEs (81%) occurred predischarge. Subspecialties with highest VTE rates were cardiothoracic (0.72%) and general surgery (0.28%). No differences were seen for elective vs. urgent/emergent procedures (p = 0.106). All-cause mortality VTE patients was 1.2% vs. 0.2% in patients without VTE (p < 0.001). After stratifying by American Society of Anesthesiologists (ASA) class, no mortality differences remained when ASA < 3. Preoperative, postoperative, and total LOSs were longer for patients with VTE (p < 0.001 for each). ASA ≥ 3, preoperative sepsis, ventilator dependence, enteral/parenteral feeding, steroid use, preoperative blood transfusion, gastrointestinal disease, hematologic disorders, operative time, and age were independent predictors (C-statistic = 0.83).

CONCLUSIONS

Pediatric postsurgical patients have unique risk factors for developing VTE.

LEVEL OF EVIDENCE

Level II.

Tales from the Night:: Emergency MR Imaging in Pediatric Patients after Hours

Overnight in-house radiology has rapidly become an important part of contemporary practice models, and is increasingly the norm in pediatric radiology. MR imaging is an indispensable first-line and problem-solving tool in the pediatric population. This has led to increasingly complex MR imaging being performed "after hours" on pediatric patients. This article reviews the factors that have led to widespread overnight subspecialty radiology and the associated challenges for overnight radiologists, and provides an overview of up-to-date imaging techniques and imaging findings of the most common indications for emergent MR imaging in the pediatric population.

Catheter-directed therapy for acute pulmonary embolism in children

BACKGROUND

Acute pulmonary embolism is a life-threatening condition and rarely occurs in children. In adults, catheter-directed therapy emerges as a potentially safer and effective therapeutic option. However, there is a paucity of data on the safety and efficacy of catheter-directed therapy for pulmonary embolism in children. We report a single-centred experience of catheter-directed therapy for acute pulmonary embolism in children.

METHODS

This is a retrospective study of children who had no CHD and underwent catheter-directed therapy at Detroit Medical Center during a 12-year period from 2005 to 2017. Demographic and clinical data associated with pulmonary embolism were collected along with the outcome.

RESULTS

A total of nine patients of median age 16 years with the range from 12 to 20 received catheter-directed therapy for sub-massive (n = 6) and massive pulmonary embolism (n = 3). Among nine patients, one patient received Angiojet thrombectomy and balloon angioplasty, whereas eight patients received catheter-directed thrombolysis using tissue plasminogen activator through infusion catheters (n = 3) or EkoSonic ultrasound-accelerated thrombolysis system (n = 5). In four out of five patients treated with EkoSonic, significant clinical improvement was noticed within 24 hours. Among seven patients who survived, two patients had minor gastrointestinal bleeding with median hospital stay of 8 days with the range from 5 to 24 days, and two patients with massive pulmonary embolism died possibly due to delayed institution of catheter-directed therapy.

CONCLUSION

Catheter-directed therapy with/without EkoSonic is an emerging alternative therapy for sub-massive and massive pulmonary embolism in children. A timely institution of catheter-directed therapy appeared important to improve the outcome.