title: Outcomes using a clinical practice pathway for the management of pulse loss following pediatric cardiac catheterization.
abstract: OBJECTIVE
  Objectives To describe the results of a clinical practice pathway (CPP) for the management of postcatheterization pulse loss in a children's hospital.
  
  
  BACKGROUND
  Standardized approaches to the diagnosis and management of postcatheterization arterial thrombus are lacking. As a result, substantial practice variation exists.
  
  
  METHODS
  Data collected prospectively for quality improvement purposes were retrospectively reviewed.
  
  
  RESULTS
  Since initiation of the CPP, 93/1,672 (5.4%) catheterizations resulted in pulse loss at a median patient age and weight of 73 days (1 day-5.8 years) and 4.8 kg (2-14.1 kg). Arterial thrombus was documented by ultrasound (US) in 85. Of these, 66 resolved by 12 weeks of therapy, seven patients died, and four were lost to follow-up before completing treatment. Eight patients had persistent thrombus despite a full treatment course (89% success rate in those able to complete treatment). Of patients treated with unfractionated heparin as initial therapy, 46% (17/37) achieved a therapeutic partial thromboplastin time within 12 hr with 19% (67/343) of all levels therapeutic. As a result, the CPP was modified to use enoxaparin as first line agent, of which 57% (41/72) had a therapeutic anti-Xa level after the 2nd dose and 88% by the 4th dose. No bleeding complications were observed. A priori established process metrics were achieved.
  
  
  CONCLUSIONS
  A CPP utilizing early initiation of anticoagulation and US to aid diagnosis of postcatheterization arterial thrombus and response to therapy is feasible and effective. In those able to complete up to 12 weeks of treatment, resolution occurs in nearly 90%. © 2014 Wiley Periodicals, Inc.
authors.affiliation: Division of Cardiology, Children's Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania.
authors.forename: Andrew C
authors.initials: AC
authors.lastname: Glatz
authors.forename: Rachel
authors.initials: R
authors.lastname: Keashen
authors.forename: Julie
authors.initials: J
authors.lastname: Chang
authors.forename: Lisa-Ann
authors.initials: LA
authors.lastname: Balsama
authors.forename: Yoav
authors.initials: Y
authors.lastname: Dori
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Gillespie
authors.forename: Therese M
authors.initials: TM
authors.lastname: Giglia
authors.forename: Leslie
authors.initials: L
authors.lastname: Raffini
authors.forename: Jonathan J
authors.initials: JJ
authors.lastname: Rome
mesh_terms: D000367:Age Factors; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000209:etiology / Q000401:mortality / Q000503:physiopathology; D006328:Cardiac Catheterization / Q000009:adverse effects* / Q000401:mortality; D002648:Child; D002675:Child, Preschool; D019091:Critical Pathways; D004334:Drug Administration Schedule; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D006470:Hemorrhage / Q000139:chemically induced; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D017063:Outcome Assessment, Health Care; D015143:Philadelphia; D011237:Predictive Value of Tests; D011674:Pulse; D012189:Retrospective Studies; D012307:Risk Factors; D013927:Thrombosis / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000209:etiology / Q000401:mortality / Q000503:physiopathology; D013997:Time Factors; D016896:Treatment Outcome; D014463:Ultrasonography
chemical_list: D000925:Anticoagulants; D005343:Fibrinolytic Agents
keywords: anticoagulants; complications; complications-pediatric catheterization; congenital heart disease/pediatrics; vascular access