Recommendations for future research in relation to pediatric pulmonary embolism: communication from the SSC of the ISTH

Biss, Tina; Rajpurkar, Madhvi; Williams, Suzan; Ommen, C. Heleen van; Chan, Anthony; Goldenberg, Neil A.; Thrombosis, Neonatal

doi:10.1111/jth.13902

Cited by 13 publications

(12 citation statements)

References 19 publications

(36 reference statements)

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“…8,13 Management of asymptomatic PE lacks evidence, but most physicians claim to treat them similarly to symptomatic PE. 26 In a literature review, 8 up to 17% of patients had PE detected incidentally but details on diagnostic methods, treatment and outcomes of this type of PE in pediatric patients had not been reported.…”

Section: Discussionmentioning

confidence: 99%

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

Bragança

Gorito

Cibele

et al. 2021

Pediatric Pulmonology

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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 autoimmunity (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.

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Section: Discussionmentioning

confidence: 99%

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

Bragança

Gorito

Cibele

et al. 2021

Pediatric Pulmonology

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“…Recently, two distinct patterns of pediatric PE have been acknowledged 8 : classic thromboembolic PE and in situ pulmonary artery thrombosis (ISPAT), which results from local causes, such as congenital heart disease or anomalies of the pulmonary artery 26 . Two patients from our study may fit into this category: an asymptomatic (table 2) and a 13-years old girl, with a Truncus arteriosus type 1, with a right ventricle-pulmonary artery conduct, hospitalized with endocarditis suspicion.…”

Section: Discussionmentioning

confidence: 99%

Pulmonary embolism in pediatric age: a retrospective study from a tertiary Centre

Bragança¹,

Gorito²,

Cibele³

et al. 2021

Preprint

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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 PE diagnostic prediction tools. Methods: Retrospective, descriptive study of PE cases admitted from 2008 to 2020. Data was collected from hospital records. Patients were grouped according to PE severity and setting (outpatients, inpatients). Associations with demographic characteristics, risk factors, clinical presentation, management and outcomes were analyzed. PE diagnostic prediction tools were applied. Results: 29 PE episodes occurred in 27 patients, 62.9% female, mean age 14.1 years. Most PE were central and massive or submassive. One was diagnosed in autopsy. Outpatients (n=20), admitted for classic PE symptoms, were adolescents; in half the diagnosis had been missed previously. Risk factors included contraceptives (65%), thrombophilia (35%), obesity (20%) and auto-immunity (20%). Inpatients´ PE (n=8), 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 adults’ scores performed better than pediatrics’ scores (sensitivity 92.9-96% vs 85.7- 92.9%). Both pediatrics’ scores missed a case with a positive family history. Discussion: Pediatric PE diagnosis is often delayed or missed. To improve it, the development of pediatric prediction tools as from validated adult scores merits to be explored. We propose that clinical presentation and risk factors may be different in inpatients and outpatients. Family history should be included.

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“…The most recent major recommendation by the Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis outlines the need to improve awareness and education for the prompt investigation and diagnosis of pulmonary thromboses in children. 87 Thromboembolic PE and in situ pulmonary artery thromboses are likely underrecognized in pediatric ARDS cases, and their current role in patient outcomes is unknown. Awareness of patients at risk for pulmonary thrombosis within the heterogeneous context of pediatric ARDS should be coupled with diagnostic pathways that might include changes in the ventilatory dead space fraction and emerging bedside technologies.…”

Section: Discussionmentioning

confidence: 99%

Pulmonary Thromboses in Pediatric Acute Respiratory Distress Syndrome

Caudron¹,

Holt²,

Cuvelier³

et al. 2018

Respir Care

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Pediatric ARDS continues to be a management challenge in the ICU with prolonged hospitalizations and high mortality. Thromboembolic pulmonary embolism and in situ pulmonary artery thrombosis might represent underappreciated thrombotic processes for a subset of these patients. Although well described in the adult literature, descriptions of pulmonary thromboses with pediatric ARDS are limited to case reports. However, many risk factors for pulmonary thromboses are present in children with ARDS (eg, coagulopathy, endothelial injury, central venous catheters, concomitant inflammatory diseases), suggesting a much higher incidence is plausible. Based on an interpretation of animal, pediatric, and adult data, we propose a diagnostic algorithm to facilitate a timely and accurate diagnosis. Observing an alveolar dead space fraction > 0.25, or either a 50% increase in physiologic dead space/tidal volume or a central venous saturation < 60% over 24 h, triggers the algorithm. Together with targeted heparin treatment and right ventricular afterload reduction, clinical outcomes might improve if this particular patient subgroup can be identified early. While anticoagulation is recommended in adults with confirmed pulmonary embolism and low early mortality risk, data for children are limited.

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Recommendations for future research in relation to pediatric pulmonary embolism: communication from the SSC of the ISTH

Cited by 13 publications

References 19 publications

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

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

Pulmonary embolism in pediatric age: a retrospective study from a tertiary Centre

Pulmonary Thromboses in Pediatric Acute Respiratory Distress Syndrome

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