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Important: please update your RDS app to version 4.7.3

Welcome to the March 2025 update from the RDS team

1.     RDS issues - resolutions

1.1 Stability issues - Tactuum implemented a fix on 24th March which we believe has finally addressed the stability issues experienced over recent weeks.  The issue seems to have been related to the new “Tool export” function making repeated calls for content when new toolkit nodes were opened in Umbraco. No outages have been reported since then, and no performance issues in the logs, so fingers crossed this is now resolved.

1.2 Toolkit URL redirects failing– these were restored manually for the antimicrobial calculators on the 13th March when the issue occurred, and by 15th March for the remainder. The root cause was traced to adding a new hostname for an app migrated from another health board and made live that day. This led to the content management system automatically creating internal duplicate redirects, reaching the maximum number of permitted redirects and most redirects therefore ceasing to function.

This issue should not happen again because:

  • All old apps are now fully migrated to RDS. The large number of migrations has contributed to the high number of automated redirects.
  • If there is any need to change hostnames in future, Tactuum will immediately check for duplicates.

1.3 Gentamicin calculators – Incidents have been reported incidents of people accessing the wrong gentamicin calculator for their health board.  This occurs when clinicians are searching for the gentamicin calculator via an online search engine - e.g. Google - rather than via the health board directed policy route. When accessed via an external search engine, the calculator results are not listed by health board, and the start page for the calculator does not make it clearly visible which health board calculator has been selected.

The Scottish Antimicrobial Prescribing Group has asked health boards to provide targeted communication and education to ensure that clinicians know how to access their health board antimicrobial calculators via the RDS, local Intranet or other local policy route. In terms of RDS amendments, it is not currently possible to change the internet search output, so the following changes are now in progress:

  • The health board name will now be displayed within the calculator and it will be made clear which boards are using the ‘Hartford’ (7mg/kg) higher dose calculator
  • Warning text will be added to the calculator to advise that more than one calculator is in use in NHS Scotland and that clinicians should ensure they access the correct one for their health board. A link to the Right Decision Service list of health board antimicrobial prescribing toolkits will be included with the warning text. Users can then access the correct calculator for their Board via the appropriate toolkit.

We would encourage all editors and users to use the Help and Support standard operating procedure and the Editors’ Teams channel to highlight issues, even if you think they may be temporary or already noted. This helps the RDS team to get a full picture of concerns and issues across the service.

 

2.     New RDS presentation – RDS supporting the patient journey

A new presentation illustrating how RDS supports all partners in the patient journey – multiple disciplines across secondary, primary, community and social care settings – as well as patients and carers through self-management and shared decision-making tools – is now available. You will find it in the Promotion and presentation resources for editors section of the Learning and support toolkit.

3.     User guides

A new user guide is now available in the Guidance and tips section of Resources for providers within the Learning and Support area, explaining how to embed content from Google Calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream and Jotforms into RDS pages. A webinar for editors on using this new functionality is scheduled for 1 May 3-4 pm (booking information below.)

A new checklist to support editors in making all the checks required before making a new toolkit live is now available at the foot of the “Request a new toolkit” standard operating procedure. Completing this checklist is not a mandatory part of the governance process, but we would encourage you to use it to make sure all the critical issues are covered at point of launch – including organisational tags, use of Alias URLs and editorial information.

4.Training sessions for RDS editors

Introductory webinars for RDS editors will take place on:

  • Tuesday 29th April 4-5 pm
  • Thursday 1st May 4-5 pm

Special webinar for RDS editors – 1 May 3-4 pm

This webinar will cover:

  1. a) Use of the new left hand navigation option for RDS toolkits.
  2. b) Integration into RDS pages of content from external sources, including Google Calendar, Google Maps and simple Jotforms calculators.

Running usage statistics reports using Google analytics

  • Wednesday 23rd April 2pm-3pm
  • Thursday 22nd May 2pm-3pm

To book a place on any of these webinars, please contact Olivia.graham@nhs.scot providing your name, role, organisation, title and date of the webinar you wish to attend.

5.New RDS toolkits

The following toolkits were launched during March 2025:

SIGN guideline - Prevention and remission of type 2 diabetes

Valproate – easy read version for people with learning disabilities (Scottish Government Medicines Division)

Obstetrics and gynaecology induction toolkit (NHS Lothian) – password-protected, in pilot stage.

Oral care for care home and care at home services (Public Health Scotland)

Postural care in care homes (NHS Lothian)

Quit Your Way Pregnancy Service (NHS GGC)

 

6.New RDS developments

Release of the redesign of RDS search and browse, archiving and version control functionality, and editing capability for shared content, is now provisionally scheduled for early June.

The Scottish Government Realistic Medicine Policy team is leading development of a national approach to implementation of Patient-Reported Outcome Measures (PROMs) as a key objective within the Value Based Health and Care Action Plan. The Right Decision Service has been commissioned to deliver an initial version of a platform for issuing PROMs questionnaires to patients, making the PROMs reports available from patient record systems, and providing an analytics dashboard to compare outcomes across services.  This work is now underway and we will keep you updated on progress.

The RDS team has supported Scottish Government Effective Prescribing and Therapeutics Division, in partnership with Northern Ireland and Republic of Ireland, in a successful bid for EU funding to test develop, implement and assess new integrated care pathways for polypharmacy, including pharmacogenomics. As part of this project, the RDS will be working with NHS Tayside to test extending the current polypharmacy RDS decision support in the Vision primary care electronic health record system to include pharmacogenomics decision support.

7. Implementation projects

We have just completed a series of three workshops consulting on proposed improvements to the Being a partner in my care: Realistic Medicine together app, following piloting on 10 sites in late 2024. This app has been commissioned by Scottish Government Realistic Medicine to support patients and citizens to become active partners in shared decision-making and encouraging personalised care based on outcomes that matter to the person. We are keen to gather more feedback on this app. Please forward any feedback to ann.wales3@nhs.scot

 

 

Enoxaparin use in neonatal and paediatric critical care

Warning Warning: This guideline is 856 day(s) past its review date.

Objectives

Guideline for the use of enoxaparin for treatment of thrombotic events within NICU & PICU, and for thromboprophylaxis within PICU

Scope

Venous thrombo-embolism prophylaxis is NOT generally indicated in neonates, infants and children.

The aim of this guideline is to delineate a treatment and monitoring pathway for Enoxaparin use in the Neonatal Intensive Care Units in the West of Scotland and Paediatric Intensive Care Unit of the Royal Hospital Sick Children, Glasgow.

It does not describe the diagnostic management of potential venous thrombo-embolism or prophylaxis against venous thrombo-embolism.

Users should also refer to the appropriate pharmacy monographs

Audience

Clinicians working in the neonatal and paediatric critical care units.

Venous thromboembolism (VTE) is being increasingly recognized in the paediatric population. The estimated incidence of VTE is 0.7 to 1.0 per 100 000 population with a prevalence of 5.3 per 10,000 hospital admission according to the Canadian VTE registry (Andrew M et al. 1994). Recent US data has shown an incidence of 1.51 VTE’s per 1000 PICU patient days or 0.74% of patients admitted to the 11 PICU’s taking part in the study by Higgerson et al (2011). There is a bi-modal distribution with peaks in the neonatal and adolescent periods. Small studies have shown a greater relative risk of VTE in children than adults.  (O’Brien et al, 2011).

The main risk factors in children are underlying medical or surgical risk factors (van Ommen CH et al, 2003) and central venous catheters (Revel-Vilk S et al, 2003; Higgerson et al, 2011). VTE is associated with increased mortality, recurrent thrombosis and post-thrombotic syndrome with an average follow-up period of 2.86 years (Monagle P at al, 2000; Higgerson et al, 2011).

A small but not insignificant number of neonates develop thrombi within the first few weeks of life, associated iatrogenically with the insertion of umbilical catheters or peripheral arterial lines, or secondary to traumatic delivery. A small number of infants have no identifiable risk factors.

Of these neonates, infants and children, a proportion will require treatment to minimise the risk of significant morbidity and mortality from this thrombotic event. Treatment in neonates is generally limited to those with evidence of end organ compromise or limb ischaemia secondary to thrombus formation, and is almost exclusively initiated in consultation with a paediatric consultant haematologist. Thromboprophylaxis is not generally indicated within the neonatal population except for in a small subgroup of infants with complex multisystem disease within paediatric critical care.

Enoxaparin should be continued for between 6 weeks and 3 months post-diagnosis of a VTE. Ensure referral to Dr Chalmers (Consultant Haematologist RHSC). Remove CVL associated with VTE as soon as possible. Ensure follow-up ultrasound to screen for extension of VTE. It is acknowledged that neonatal enoxaparin dosing can be challenging and will almost always be done in conjunction with paediatric haematology. If an infant is being discharged on enoxaparin they should be referred to haematology for follow up at discharge.

Therapeutic Enoxaparin dose regime

    1. Neonate
      • 2mg/kg TWICE DAILY subcutaneously
    2. 1 month old
      • 1.5mg/kg TWICE DAILY subcutaneously
    3. 2 months - 17 years
      • 1mg/kg TWICE DAILY subcutaneously

The following general principles apply:

  • Ideally prescribe for 0600Hrs & 1800Hrs (but do not delay commencing treatment unless converting from UFH)
  • Once target heparin assay achieved, consider switching to administration via insuflon (see Insuflon management following prophylactic regime)

 

Therapeutic Enoxaparin monitoring regime

Target heparin assay 0.5 – 1.0 U/ml

  • Check heparin assay 4 hours after 1st dose
    • Order “heparin assay (LMWH) - child” on Trakcare, stating Enoxaparin therapy and dose regime and time of last dose.
  • Dose adjust as per chart below
  • Repeat heparin assay 4 hrs after 3rd dose and dose adjust as per chart
  • Once target range achieved check heparin assay every Monday & Thursday
  • Remember heparin assay results will be affected by:
    • Use of Unfractionated Heparin
    • Delayed excretion of LMWH e.g. in renal failure
    • Hepatic failure
    • Coexisting coagulopathy e.g. in sepsis
  • Increase frequency of heparin assay if there are any bleeding concerns.

Heparin assay 

Dose adjustment

Next heparin assay

<0.35

Change Insuflon site
Dose ⬆ 25%

4 hrs post dose

0.35 – 0.49

Dose ⬆ 10%

Next day

0.5 – 1.0

 -

Next Monday or Thursday

1.01 – 1.5

Dose ⬇ 10%

Next day

1.512.0

Delay dose by 12hrs & ⬇ 25%

 

>2

Delay dose till heparin assay is <1.0
Dose ⬇ 40%

Check heparin assay every 12 hrs till <1.0
Check heparin assay 3.5 hrs after dose

VTE prophylaxis with Enoxaparin should be used in combination with measures including early mobilisation, removal of CVL’s and TED stockings (see appendix VTE Risk assessment).

Prophylactic Enoxaparin dose regime

  • < 2 months or <5kg
    • 0.75mg/kg TWICE DAILY subcutaneously
    • Prescribe for 0600Hrs & 1800Hrs
    • Once heparin assay therapeutic consider switching to administration via insuflon
  • >2 months or > 5kg
    • 0.5mg/kg TWICE DAILY subcutaneously, maximum 40mg per day
    • Prescribe for 0600Hrs & 1800Hrs
    • Once heparin assay therapeutic consider switching to administration via insuflon

Insuflon management

  • Recommendation that insuflon is changed every 7 days with date of change marked on adhesive dressing.
  • Insuflon should not be flushed due to the potential for changes in dosage and drug distribution.
  • If heparin assay out with the target range occur, change the Insuflon site

 

Prophylactic Enoxaparin monitoring regime

Target heparin assay 0.3 – 0.5 U/ml

  • Check heparin assay 4 hrs after 3rd dose
    • Order “heparin assay (LMWH) - child” on Trakcare, stating Enoxaparin therapy and dose regime and time of last dose.
  • Dose adjust as per chart below
  • Once target range achieved check heparin assay every Monday
  • Remember heparin assay results will be affected by:
    • Use of Unfractionated Heparin
    • Delayed excretion of LMWH e.g. in renal failure
    • Hepatic failure
    • Coexisting coagulopathy e.g. in sepsis
  • Increase frequency of heparin assay if:
    • Bleeding concern
    • Planned surgery

Heparin assay

Dose adjustment

Next heparin assay

<0.3

Change Insuflon site
Dose ­⬆ 25%

4 hrs post dose

0.3 – 0.5

-

4 hrs post dose on next Monday

0.5 – 1.0

Dose ⬇ 25%

Next day

>1.0

Delay dose till heparin
assay is <0.5
Dose ⬇ 40%

Check heparin assay every
12 hrs till <1.0
Check heparin assay 4 hrs after dose

Faustino et al surveyed 151 PICUs across the US looking at their thromboprophylaxis and VTE treatment policy. They had a 62.2% response rate. There was no uniform guidance seen across the centres. Similar findings were found in a survey undertaken in England and Wales. (Braga et al, 2011).  There is guidance published in 2012 from the British Committee for Standards in Haematology which was developed in light of the available evidence and expert opinion (Chalmers, E. et al 2011). This work focuses on the investigation, management and prevention of paediatric VTE and forms the core for the majority of this guideline.

Much recent literature has focussed on the use of low molecular weight heparins (LMWH) and their role and potential benefits in relation to unfractionated heparin (UFH) in the prophylaxis and treatment of VTE (Chalmers, E. et al, 2011). Enoxaparin is a LMWH, used in the intensive care settings as the primary anti-coagulant for the prophylaxis and treatment of thrombo-embolic events. The efficacy, predictable pharmacokinetics, ease of administration and the reduced side effect profile of LMWH make it superior to unfractionated heparins as the first choice anticoagulant group(Andrew et al. 1994)depending on the clinical situation.

The benefits of LMWH versus UFH include administration in that they require to be given once or twice daily subcutaneously, compared to a continuous intra-venous infusion.  Other benefits include route of administration, as the subcutaneous route negates the necessity for intravenous access, and as such reducing pain, discomfort and infection risk.  Further benefits in a study by Robinson et al are identified as less time needed to prepare, no break in therapy whilst making up new heparin syringe and a reduction in cost for LMWH versus UFH (Robinson AM et al 1993). Previous adult studies have shown that LMWH is as effective in the management of VTE as UFH. Furthermore, the pharmacokinetics are more predictable. (Massicote et al, 1996). The REVIVE study assessed the efficacy and safety of different anticoagulant regimens in children with VTE. Children with a first episode of VTE were randomised to receive either LMWH (reviparin-sodium) (N=37) or UFH followed by oral anticoagulation (UFH/VKA) (N=41) (Massicotte et al 2003a). The study was underpowered but showed LMWH was an equally effective form of anticoagulation.

Medications for children are primarily dosed based on weight, and are often metabolised and distributed differently to adults. Furthermore, the haemostatic system in neonates and infants differs from that of older children and adults, and targets for therapy may differ. Dosing regimes for anticoagulants should not simply extrapolated from data based on adults but should instead be based on pharmacokinetic and pharmacodynamic data.

Trame et al described a population pharmacokinetic model where a cohort study of 126 children identified body weight as the most predictive covariate of enoxaparin clearance. Their results, measuring anti-factor Xa activity data, suggested a regime of once daily dosing with frequent monitoring (Trame et al 2010). In contrast, an open label pilot safety study by Schobess et al looked at long term safety and efficacy data where children were stratified to receive once or twice daily enoxaparin and found no difference (Schobess et al 2006). A once daily regime may be more convenient and less likely to cause distress and discomfort to the child. A Cochrane review by van Donghen et al concluded that once-daily treatment with LMWH is as effective and safe as twice daily treatment with LMWH. However, the 95% confidence interval implies that there is a possibility that the risk of recurrent VTE might be higher when patients are treated once daily (van Donghen et al 2003).

An observational study by Dix et al looked at LMWH for the treatment of VTE in neonates and children. A clinical response was demonstrated in 94% of cases. However 5% had major bleeding and in 1% a recurrent VTE occurred. (Dix et al 2000).

Thromboprophylaxis is of increasing interest in the paediatric population as the incidence of VTE becomes more apparent. The role of physical prophylaxis is more applicable to older children, usually those greater than 40kg or in their adolescence. Pharmacological intervention with agents such as LMWH’s  may also have a role to play.

Massicotte et al (2003) carried out the PROTEKT trial which randomised 186 children to either routine care(UFH/warfarin) or LMWH. They looked at the role of prophylactic doses of LMWH in preventing VTE. They showed a non-significant difference in incidence of VTE (12.5% vs 14.1%), although the study was underpowered

Concern has been raised that the preparations for smaller children are not appropriate with LMWH’s coming in pre-filled adult dose syringes (Monagle et al. 2012)

Current literature describes the need for age-specific dosing requirements in children (Buck 2011;Ignjatovic et al. 2010;Malowany et al. 2008; Streif et al2004; Massicote et al 2003; Kuhl et a 2002). These studies suggest the following dosing schedules; for therapeutic doses, 2 mg/kg every 12 hours for children less than 2 months of age and 1.0 mg/kg for children greater than 2 months of age; for prophylactic doses, 0.75 mg/kg every 12 hours for children less than 2 months of age and 0.5 mg/kg for children greater than 2 months of age (Bauman et al. 2009;Ignjatovic et al. 2010;Massicotte et al. 2003). Variation in dosing between neonates, children and adolescents/adults arise from differences in plasma concentration of anti-thrombin, thrombin generation capacity and clearance of heparin between the age groups (Andrew et al 1998).

Monitoring enoxaparin therapy in children to ensure target levels are attained to ensure optimal effect and minimal risk of the therapy is undertaken by assessing anti-Xa levels in the patient’s serum. This test is otherwise known as a Heparin assay. 

Heparin assay should be assessed 4-6 hours after the dose of enoxaparin is administered. These levels can be used to monitor the effect of enoxaparin, ensuring it remains within the target range and, therefore optimising the dose. The dosing schedules mentioned above were extrapolated from adult guidelines to give a target plasma anti-Xa concentration of 0.1 - 0.3 u/ml in prophylactic patients and 0.5 – 1.0 u/ml in therapeutic patients, or 0.5 - 0.8u/ml in a sample taken 2-6 hours post dose (Chalmers et al. 2011, Monagle et al. 2012).

Rapid achievement of target levels of anti-Xa is important as any delay may place the child at needless risk of thrombosis, or extension of the pre-existing thrombus. A study by Bauman et al (2009) evaluated the dosing requirements of enoxaparin in children and infants, focusing on the effect of increasing the starting dose of enoxaparin and the length of time required to reach therapeutic anti-Xa levels. Their study concluded that a higher starting dose, with the subsequent doses titrated according to the anti-Xa level, resulted in a quicker achievement of target anti-Xa levels than is observed by following the current guidelines (Massicotte et al. 2003;Streif et al. 2003). An example of a dosing regimen with adjustments made against post-dose anti-Xa level scan be seen in table 1 (Manna; 2012). It is taken from the guidelines for the treatment of thromboembolism in use at the PICU: St George’s hospital, London,

Once target levels have been achieved, it is suggested that monitoring should be done a minimum of once a week to ensure that the optimum dose of enoxaparin is being maintained (Michaels et al. 2004).

Regular anti-Xa monitoring once target levels have been met is equally as important as the monitoring at the commencement of therapy. A study by Michaels et al (2004) retrospectively reviewed a patient group on enoxaparin therapy and observed that of the 10 patients in their study; only one patient maintained a stable anti-Xa level in the therapeutic range 100% of the time. This highlights the importance of on-going anti-Xa monitoring once target levels have been met.

Ignjatovic et al reviewed the records of 233 patients (ages 3 days to 16 years) treated with enoxaparin. All patients received enoxaparin 0.5-0.75 mg/kg twice daily. 81% were being treated with enoxaparin for a diagnosed clot, while 19% received prophylaxis. Use of anti-Xa monitoring was more frequent in patients under a year of age compared to older children and in patients treated for more than 60 days compared to those with shorter treatment courses (both comparisons, p < 0.05). 39% had an anti-Xa value within the target range of 0.5-1.0 IU/mL. 52% were subtherapeutic and 9% had values above 1.0 IU/mL.  More infants than older children were subtherapeutic on their initial enoxaparin regimen (p < 0.05). While age playes a significant role in dosing, they did not find any difference between term and preterm infants. 29% experienced minor bleeding. Only 1 patient experienced major bleeding.

Sanchez et al also found that they required higher doses of enoxaparin in infants and younger children in their cardiac intensive care unit. They carried out a retrospective study on 31 patients ranging in age from birth to 2 years. 68% received treatment doses and the rest received prophylaxis. For analysis they divided into two groups: younger patients (0-2months) and older patients. Both age groups required an increase in their enoxaparin doses to achieve an anti Xa value within the target range. Furthermore, no difference was found in dosing requirements between those patients who received direct subcutaneous injection and those using an Insuflon device. No bleeding complications were identified, however, they were using small numbers.

Work in our department has shown a wide range of doses being utilised with a poor attainment of effective aXa levels for both prophylactic and therapeutic regimes (tables 1 & 2). This has led to the development of this guideline and ready reckoner for the use of Enoxaparin in PICU & NICU.

 

Therapeutic group
(n=15)

Prophylaxis group
(n=24)

Cardiac prophylaxis group
(n=11)

 

Median

Range

Median

Range

Median

Range

Duration of Enoxaparin therapy (days)

16.5

4.5 – 101.5

4.0

0.8 – 31.6

9.0

1.5 – 22.4

Starting dose (mg/kg)

1.08

0.53 – 1.75

0.5

0.31 – 1.02

0.92

0.31 – 2.05

Therapeutic dose (mg/kg)

1.51

1.08 – 4.0

0.54

0.31 – 1.02

0.88

0.49 – 1.48

Difference b/w starting and therapeutic dose (mg/kg)

0.55

0 – 2.47

0

0.0 – 0.07

0

0

 

Number

Percentage

Number

Percentage

Number

Percentage

Concurrent aspirin administration

2

13.3%

3

12.5%

2

18.2%

Concurrent heparin administration

2

13.3%

3

12.5%

0

0

Table 1: RHSC Critical Care Enoxaparin dosing data (R Hunter, G Kerr, S Cassim, C Granger, E Chalmers, M Davidson)

 

Therapeutic group
(=15)

Prophylaxis group
(n=24)

Cardiac prophylaxis group

(n=11)

 

Median

Range

Median

Range

Median

Range

Time: 1st dose – anti-Xa
assay taken (days)

0.8

0.1 – 8.2

1.2

0.3 – 3.6

2.1

0.7 – 6.1

Time taken to reach therapeutic
level (days)

9.9

1.7 – 24.4

2.2

0.3 – 3.6

1.6

0.7 – 6.5

No. anti-Xa  assays performed
during Enoxaparin therapy

5

0 - 27

3

1 – 4

3

1 - 5

 

Number

Percentage

Number

Percentage

Number

Percentage

Patients having anti-Xa
assay performed

14

93.3%

4

16.7%

7

63.6%

Patients reaching target
Anti-Xa level

8

53.3%

4

16.7%

6

54.5%

Table 2: RHSC Critical Care Enoxaparin monitoring data (R Hunter, G Kerr,  S Cassim, C Granger, E Chalmers, M Davidson)

Therapeutic Enoxaparin dose regime

  • Prescribe for 0600h and 1800h
  • Neonate
    • 2mg/kg bd via insuflon
  • 1 - 2 months
    • 1.5mg/kg bd via insuflon
  • >2 months or > 5kg
    • 1mg/kg bd via insuflon
    • Prescribe for 0600Hrs & 1800Hrs

Heparin assay 

Dose adjustment

Next heparin assay

<0.35

Change Insuflon site
Dose ⬆ 25%

4 hrs post dose

0.35 – 0.49

Dose ⬆ 10%

Next day

0.5 – 1.0

 -

Next Monday or Thursday

1.01 – 1.5

Dose ⬇ 10%

Next day

1.512.0

Delay dose by 12hrs & ⬇ 25%

 

>2

Delay dose till heparin assay is <1.0
Dose ⬇ 40%

Check heparin assay every 12 hrs till <1.0
Check heparin assay 3.5 hrs after dose

 

Prophylactic Enoxaparin therapy

  • Prescribe for 0600h and 1800h
  • < 2 months or <5kg
    • 0.75mg/kg bd via insuflon
  • >2 months or > 5kg
    • 0.5mg/kg bd via insuflon

Heparin assay

Dose adjustment

Next heparin assay

<0.3

Change Insuflon site
Dose ­⬆ 25%

4 hrs post dose

0.3 – 0.5

-

4 hrs post dose on next Monday

0.5 – 1.0

Dose ⬇ 25%

Next day

>1.0

Delay dose till heparin
assay is <0.5
Dose ⬇ 40%

Check heparin assay every
12 hrs till <1.0
Check heparin assay 4 hrs after dose

Editorial Information

Last reviewed: 19/11/2019

Next review date: 01/12/2022

Author(s): Dr Claire Granger – ST6 neonatal grid trainee – WoS; R Hunter – medical student – University of Glasgow; Dr Sumaiya Cassim – ST8 neonatal grid trainee – North; Dr Mark Davidson – Consultant Intensivist – PICU RHSC; Dr Judith Simpson – Consultant Neonatologist – RHSC; Dr Elizabeth Chalmers – Consultant Haematologist – RHSC.

Version: 3

Approved By: Paediatric Drugs & Therapeutics Committee

References

This guideline was referenced following published literature since 1990 and by searching Medline for publications using the key word venous thrombosis and limits of humans, children and English language.

Andrew M, Marzinotto V, Blanchette V, et al : Heparin therapy in pediatric patients: a prospective cohort study. Pediatric Research 1994; 35:78‐83

Andrew M et al: Venous Thromboembolic Complications (VTE) in Children: First Analyses of the Canadian Registry of VTE. Blood 1994: 83 (5) ; 1251‐1 257

Andrew M, Michelson AD, Bovill E, Leaker M and Massicotte P: Guidelines for antithrombotic therapy in pediatric patients. Journal of Paediatrics 1998; 132: 575‐88

Anti‐coagulation Therapy for Post‐op Cardiac Patients in PICU. Royal Hospital for Sick Children PICU 2010

Attard C, Monagle P, Kubitza D, Ignjatovic V: The in vitro anticoagulant effect of rivaroxaban in children. Thrombosis Research 2012; 130: 804–807

Bauman M et al: Evaluation of enoxaparin dosing requirements in infants and children: Better dosing to achieve therapeutic levels. Thromb Haemost 2009; 101: 86–92

Buck ML: Heparin and Enoxaparin in Infants and Children: Literature Update. Paediatric Pharmacotherapy 2011; 17 (9)

Chalmers EA, Ganesen GJ, Liesner R, Maroo S, Nokes TJC, Saunders D, Williams MD: Guideline on the investigation, management and prevention of venous thrombosis in children. British Committee for Standards in Haematology

Chana AK et al: Dose‐finding and pharmacokinetic profiles of prophylactic doses of a low molecular weight heparin (reviparin–sodium) in pediatric patients. Thrombosis Research 2003; 109: 93– 99

Dix D. Andrew M. Marzinotto V. Charpentier K. Bridge S. Monagle P. deVeber G. Leaker M. Chan AK. Massicotte MP: The use of low molecular weight heparin in pediatric patients: a prospective cohort study. J Pediatr 2000; 136: 439‐445

Faustino E. et al: Survey of pharmacological thromboprophylaxis in critically ill children. Crit Care Med. 2011; 39(7): 1773–1778

Fragou M, Gravvanis A, Dimitriou V, et al: Real‐time ultrasound‐guided subclavian vein cannulation versus the landmark method in critical care patients: A prospective randomized study. Crit Care Med 2011; 39:1607–1612

Ignjatovic V, Najid S, Newall F, Summerhayes R and Monagle P: Dosing and monitoring of enoxaparin (Low molecular weightheparin) therapy in children. British Journal of Haematology 2010; 149: 734–738

Jackson P and Morgan J: Perioperative thromboprophylaxis in children: development of a guideline for management. Pediatric Anesthesia 2008; 18: 478–487

Kozul C, Newall F, Monagle P, Mertyn E and Ignjatovic V: A clinical audit of antithrombin concentrate use in a tertiary paediatric centre. Journal of Paediatrics and Child Health 2012; 48: 681–684

Male C, Chait P, Andrew M, Hanna K, Julian J, Mitchell L: Central Venous line‐related thrombosis in children: Association with central venous line location and insertion technique. Blood. 2003; 101(11): 4273‐8.

Male C, Julian JA, Massicotte P, Gent M, Mitchell L, PROTEKT study group. Significant association with location of central venous line placement and risk of venous thrombosis in children. Thromb Haemost. 2005 Sep; 94(3): 516‐21.

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Evidence method

This guideline was referenced following published literature since 1990 and by searching Medline for publications using the key word venous thrombosis and limits of humans, children and English language.