الفهرس 
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Abstract
The presence of a CVC and admission to the intensive care unit is the most important risk factors for deep venous thrombosis in children. At least 18% of critically ill children with a CVC develop radiologically confirmed catheter-associated thrombosis. Clinically apparent thrombosis occurs in 17.5% of critically ill children with a CVC. Even when the thrombus is initially asymptomatic, 8 to 18% of critically ill children with CAT develop post-thrombotic syndrome. Thrombosis is uncommon within 24 hours after insertion of a no tunneled catheter in critically ill children, but nearly all thrombi have developed by 4 days after insertion. Hypercoagulability during or immediately after insertion of the catheter plays an essential role in the development of thrombosis. Pharmacologic prophylaxis, including local anticoagulation with a heparin-bonded catheter, has not been shown to reduce the risk of CAT in children. Systemic anticoagulation in critically ill children started soon after the insertion of the catheter, however, may be beneficial. Deep venous thrombosis is a significant problem in critically ill children. The most important risk factor for DVT is the presence of a CVC. DVT develops in approximately 17.5% of critically ill children with CVC. The risk for CVC-related DVT is low within 24 hours after insertion of the CVC but significantly increases thereafter. Although routinely used in critically ill, pharmacologic thromboprophylaxis is not recommended in children with CVC due to the paucity of studies to support this practice. It would be ideal to provide thromboprophylaxis only to critically ill children at high risk for CVC-related DVT. No test has been known to identify these children. The no tunneled type of central venous catheter is usually inserted when children are critically ill and likely hypercoagulable. Coagulation factors, particularly factor VIII, increase during critical illness. FVIII activity>150 IU/dL is associated with 2.6 to 4.8-fold odds of developing DVT in adults. Due to advances in caring for critically ill children and those with chronic diseases, rates of deep vein thrombosis are increasing in children. Risk factors consist of central venous catheters chronic medical conditions, thrombophilia, and various medications. Compression Doppler ultrasonography is the method most commonly used to diagnose DVT. It was hypothesized that factor VIII activity, when measured soon after insertion of a non-tunneled CVC, could be used to stratify critically ill children based on their risk for CVC related DVT in the future. This work aims to identify critically ill children at risk for central venous Catheter-associated thrombosis to target them for thromboprophylaxis. This prospective study was carried out on 55 pediatric patients from 2.5 to 108 months (28 males and 27 males) admitted to PICU, Tanta University Hospital. Patients were categorized into 3 groups: • group I: Fifteen patients with FVIII activity <100 % • group II: twenty patients with FVIII activity from 100 % to 150 % • group III: twenty patients with FVIII activity>150 %. Results: • There was no significant difference in demographic and anthropometric data throughout the study between the studied groups. • Complete blood count has no statistically significant difference throughout the study between the studied groups. • There was no statistically significant difference in PT, PTT (second), and INR throughout the study between the studied groups. • There was no statistically significant difference in ESR (mm/hr.) throughout the study between the studied groups. • There was no statistically significant difference in ALT, AST, Serum albumin (g/dl), and CRP throughout the study between the studied groups. • There was no statistically significant difference in central line type and size throughout the study between the studied groups. • Regarding the comparison of US between The Studied Groups: There was no statistically significant difference throughout the study between the studied groups. There was a statistically significant increase in the incidence of IV echoic material in group III compared with groups I, and II. • There was a significant increase in the incidence of risk factors in group III compared with groups I, and II. • There was a significant increase in CVC occlusion in group III compared with groups I, and II. • There was a significant decrease of D-dimer on the 7th day compared with the 1st day in groups I, and II compared with group III. • There was a significant increase in Patients who received Alteplase® in group III compared with groups I, and II. • In a comparison of FVIII activity between the studied groups. There was a significant increase of FVIII activity in group III compared with groups I, and II on 1st day of the central line also, there was a statistically significant increase of FVIII activity in group III compared with groups I, and II on the 7th day of a central line. • There was a significant increase in FVIII activity (1st day) in presence of risk factors (TPN: total parenteral nutrition and MV: mechanical ventilation). • There was no significant difference in FVIII activity (1st day) with other data (gender and central line). • In comparison effects of other data (risk factors, gender, and central line) on FVIII activity (7th day). There was a significant increase in FVIII activity in presence of risk factors (use of TPN or MV). There was no statistically significant difference in FVIII activity (7th day) with other data (gender and central line). • There was a significant increase in the risk of mortality in group III compared with groups I, and II. • FVIII activity was a significant predictor for central venous line thrombosis with cut-off value>152, sensitivity100, specificity 80, PPV 93.7, and NPV 100. It was concluded that: • F VIII activity was a significant predictor for central venous line thrombosis. • Enoxaparin sodium® was effective as thromboprophylaxis with a dose (of 0.5 mg/kg subcutaneously every 12 hours) within normal range of factor VIII (up to 150%). • Alteplase® dosing for CVC occlusion based on patient weight category and the volume of the affected catheter lumen with efficacy 73.33%. It is recommended to: use factor VIII activity as a predictor/prognostic test in critically ill patients for early detection of central venous line associated thrombosis Initiate a wide-scale multicenter study to declare the issue of survival with central venous line enrolment. Daily US for early detection of central venous line associated thrombosis in patients with F VIII activity >150 % Once CVC is inserted, start early thromboprophylaxis on recommended dose. Once CVC occluded by thrombus, early treatment with Alteplase on recommended dose.